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Know Your Plan: Annual Out-of-Pocket Threshold

What Counts Toward Out-of-Pocket Costs

It is important to understand that not all out-of-pocket costs count towards this threshold. Only costs that are "covered" by your health plan count. Costs that count include:

• Deductibles.
• Costs while in the coverage gap (or "donut hole") period.
• Copays for covered medications. Covered medications are medicines that are on the formulary (in any tier) and that you get from a pharmacy approved by your plan, or via the plan's mail order service.
• Costs for medications that are not normally covered, but which have been covered for you based on an exception or appeal.