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Know Your Plan: Annual Out-of-Pocket Threshold

What Does Not Count Toward Out-of-Pocket Costs

Costs that do not count towards the cap include costs for drugs that the plan does not normally cover, such as:

• Over-the-counter medications
• Medicines that are excluded from Medicare coverage by law—such as cosmetic drugs, fertility drugs, or drugs for weight control
• Medicines that are denied by the plan because they are not on the plan's formulary
• Medicines that are denied by the plan because they are not prior authorized
• Medicines that are covered under Medicare Part A (hospital coverage) or Medicare Part B (outpatient coverage)
• Medicines purchased from an out-of-network pharmacy (unless it is an emergency)