Amount Insured Member Pays During Stage
Trigger to Move to Next Stage
All drug costs
Meet plan's deductible ($0-$445)
2. Initial Coverage
Fixed co-payments or co-insurance
Reach $4,130 in covered drug costs (considered as the out of pocket payments plus amounts paid by insurance)
3. Coverage Gap (Donut Hole)
Generic drugs: 25%
Brand-name drugs: no more than 25%
Reach $6,550 in out-of-pocket costs (includes costs for covered drugs paid since the beginning of the year plus the value of discounts† received on brand-name drugs while in this stage)
4. Catastrophic Coverage
Generic drugs: the greater of $3.70 or 5%
Brand-name drugs: the greater of $9.20 or 5%
* Data shown are for 2021 and may be different after that year.
† For brand-name drugs, there is typically a manufacturer discount of about 50% of the price. This amount is counted as part of the out-of-pocket cost, which will help people get out of the coverage gap sooner.