Why Did My Prescription Cost Change? Understanding...
Why Did My Prescription Cost Change? Understanding Deductibles, Coinsurance, and Out-of-Pocket Maximums
ACMA
Sep 17, 2026
5 minutes read
Why Did My Prescription Cost Change? Understanding Deductibles, Coinsurance, and Out-of-Pocket Maximums
Have you ever picked up a script for the same prescription and wondered why the cost was so cheap that month but expensive the next time you picked up that same script, while the rest of your insurance plan had stayed the exact same? The difference isn't the medicine; it is where you are in your health insurance plan year.
Your three most important components of your insurance plan (deductible, coinsurance, and out-of-pocket max) will all have an effect on your costs for prescriptions and other medical care throughout the course of the year. Knowing how these work together with each other will make understanding your prescription costs as well as overall health care costs a lot easier.
What Is a Deductible?
A deductible is the cost you incur prior to your health insurance company beginning payment on various health-related services. For instance, let's say you are required to pay $1500 out of pocket for treatment related to a deductible; in this case, the health insurance company will begin to reimburse you for covered services after the first $1500 of charges have been incurred by you. Not all services are treated similarly. Some plans cover specific services before meeting your deductible. In addition, there are some plans with a separate deductible for prescriptions.
What Is Coinsurance?
Once you have reached your deductible (the minimum amount that you will need to pay out-of-pocket before your health care provider will begin to cover part of your costs), you will be required to pay a portion of each expense for medical services, in the form of coinsurance (coins). Coinsurance is based on a percentage of the allowed amount of each individual medical service. For instance, let’s assume an insurance company has established an allowed amount of $100 per procedure. If your insurance policy calls for a 20% coinsurance, then you would owe 20% of the $100. The other 80% of the $100 would be paid by your insurance carrier.
What Is an Out-of-Pocket Maximum?
Your out-of-pocket (OOP) maximum is what you are allowed to spend per calendar year for "covered" expenses (excluding deductibles, co-pays, and coinsurance) received from an in-network provider. When you reach your OOP maximum for the calendar year, then your health plan will pay all of the remaining "covered" services at 100% for the remainder of that calendar year. However, there are many things that you may be spending money on that will NOT count toward your out-of-pocket Maximum.
Become excellent in prior authorization, reimbursement & market access — enroll today
Why Did My Prescription Cost Change? Understanding Deductibles, Coinsurance, and Out-of-Pocket Maximums
ACMA
Sep 17, 2026
5 minutes read
Why Did My Prescription Cost Change? Understanding Deductibles, Coinsurance, and Out-of-Pocket Maximums
Have you ever picked up a script for the same prescription and wondered why the cost was so cheap that month but expensive the next time you picked up that same script, while the rest of your insurance plan had stayed the exact same? The difference isn't the medicine; it is where you are in your health insurance plan year.
Your three most important components of your insurance plan (deductible, coinsurance, and out-of-pocket max) will all have an effect on your costs for prescriptions and other medical care throughout the course of the year. Knowing how these work together with each other will make understanding your prescription costs as well as overall health care costs a lot easier.
What Is a Deductible?
A deductible is the cost you incur prior to your health insurance company beginning payment on various health-related services. For instance, let's say you are required to pay $1500 out of pocket for treatment related to a deductible; in this case, the health insurance company will begin to reimburse you for covered services after the first $1500 of charges have been incurred by you. Not all services are treated similarly. Some plans cover specific services before meeting your deductible. In addition, there are some plans with a separate deductible for prescriptions.
What Is Coinsurance?
Once you have reached your deductible (the minimum amount that you will need to pay out-of-pocket before your health care provider will begin to cover part of your costs), you will be required to pay a portion of each expense for medical services, in the form of coinsurance (coins). Coinsurance is based on a percentage of the allowed amount of each individual medical service. For instance, let’s assume an insurance company has established an allowed amount of $100 per procedure. If your insurance policy calls for a 20% coinsurance, then you would owe 20% of the $100. The other 80% of the $100 would be paid by your insurance carrier.
What Is an Out-of-Pocket Maximum?
Your out-of-pocket (OOP) maximum is what you are allowed to spend per calendar year for "covered" expenses (excluding deductibles, co-pays, and coinsurance) received from an in-network provider. When you reach your OOP maximum for the calendar year, then your health plan will pay all of the remaining "covered" services at 100% for the remainder of that calendar year. However, there are many things that you may be spending money on that will NOT count toward your out-of-pocket Maximum.
Become excellent in prior authorization, reimbursement & market access — enroll today
How Do These Three Work Together Across a Plan Year?
Think about your health care expenses by stages of the year.
You start in January (the first month) of the plan year before meeting your deductible. When receiving health care services or prescription medications that apply to your deductible, you will typically pay the larger share of the expense.
At mid-year, you accumulate enough health care expenses to meet your deductible. For the remainder of the year, your health care plan will split eligible medical expenses with you. Depending on how your plan is structured, this can include coinsurance, which is usually expressed as a percentage of the allowed amount. In such cases, you would pay your designated percentage, and your insurance company would cover the remaining portion.
Later in the year, as long as your plan has those three components (deductible, copays, and/or coinsurance), it is possible that your total expenses for all three components could cause you to reach your out-of-pocket maximum. After reaching your maximum amount, your plan covers 100% of covered in-network medical expenses for the balance of the plan year.
As noted previously, your actual out-of-pocket expenses and timing for when you reach each stage vary depending upon both your particular health care plan and how often you utilize health care services.
Where Can Discount Cards Help?
Prescription discount cards often complicate the process. For example, SingleCare is a prescription discount service and not health insurance. You can't use both your SingleCare discount and your insurance for the same prescription claim when you opt to pay the SingleCare price. Instead, you're opting to use the discount instead of having your insurance cover that prescription claim.
The reason this is important is that a SingleCare purchase does NOT apply to your insurance deductible. Whether or not you can get reimbursed from your insurance for a SingleCare purchase depends on what type of plan you have.
While a discount card may give you a better deal for a prescription right now, it doesn't always represent the best option over time. Consider whether paying with a discount card as opposed to using your insurance will move you closer to meeting your insurance deductible and all other limits in your plan before deciding which way to go.
Quick Comparison
Deductible
Coinsurance
Out-of-Pocket Maximum
Term
The amount you pay prior to your plan beginning to share specific amounts of covered expenses
Typically paid prior to meeting your deductible.
What It Means
A percentage of an expense which has been deemed as "covered" by your insurance company.
Commonly paid after meeting your deductible.
When It Applies
The total amount you are required to pay for services (in-network) that are eligible for the out-of-pocket max each calendar year.
After the out-of-pocket max is met, the plan covers all eligible in-network services at 100%.
What Can You Do?
To find this information, check your health insurance company's Member Portal or look up your Summary of Benefits and Coverage (SBC). A SBC describes your plan's benefits, costs, restrictions, and exclusions. Look at the Deductible section to see if you've already spent money on it; review the Coinsurance area to determine what percent of charges you'll be responsible for paying; then go to the "Out of Pocket Max" to see how much you can spend on medical expenses before your insurance company begins covering 100% of eligible in-network expenses.
Prior to using an Rx Discount Card for a prescribed medication instead of using your health insurance for coverage, compare the cost difference immediately prior to use and also call your health insurance provider to confirm whether the amount paid using the discount card can be submitted for reimbursement applied toward your deductible or out-of-pocket maximum.
Bottom Line
Your costs for prescriptions may be changing throughout the year regardless of changes to your health insurance. In addition to an annual deductible, your coinsurance (percentage of charges), and your maximum out-of-pocket expense all contribute to how much of your expenses will be paid by your insurance company versus you. Being aware of which phase of your benefits cycle you are currently experiencing, along with the method in which your prescription(s) were obtained (insurance, discount card, etc.), will provide you insight into the amounts being charged and why.
How Do These Three Work Together Across a Plan Year?
Think about your health care expenses by stages of the year.
You start in January (the first month) of the plan year before meeting your deductible. When receiving health care services or prescription medications that apply to your deductible, you will typically pay the larger share of the expense.
At mid-year, you accumulate enough health care expenses to meet your deductible. For the remainder of the year, your health care plan will split eligible medical expenses with you. Depending on how your plan is structured, this can include coinsurance, which is usually expressed as a percentage of the allowed amount. In such cases, you would pay your designated percentage, and your insurance company would cover the remaining portion.
Later in the year, as long as your plan has those three components (deductible, copays, and/or coinsurance), it is possible that your total expenses for all three components could cause you to reach your out-of-pocket maximum. After reaching your maximum amount, your plan covers 100% of covered in-network medical expenses for the balance of the plan year.
As noted previously, your actual out-of-pocket expenses and timing for when you reach each stage vary depending upon both your particular health care plan and how often you utilize health care services.
Where Can Discount Cards Help?
Prescription discount cards often complicate the process. For example, SingleCare is a prescription discount service and not health insurance. You can't use both your SingleCare discount and your insurance for the same prescription claim when you opt to pay the SingleCare price. Instead, you're opting to use the discount instead of having your insurance cover that prescription claim.
The reason this is important is that a SingleCare purchase does NOT apply to your insurance deductible. Whether or not you can get reimbursed from your insurance for a SingleCare purchase depends on what type of plan you have.
While a discount card may give you a better deal for a prescription right now, it doesn't always represent the best option over time. Consider whether paying with a discount card as opposed to using your insurance will move you closer to meeting your insurance deductible and all other limits in your plan before deciding which way to go.
Quick Comparison
Deductible
Coinsurance
Out-of-Pocket Maximum
Term
The amount you pay prior to your plan beginning to share specific amounts of covered expenses
Typically paid prior to meeting your deductible.
What It Means
A percentage of an expense which has been deemed as "covered" by your insurance company.
Commonly paid after meeting your deductible.
When It Applies
The total amount you are required to pay for services (in-network) that are eligible for the out-of-pocket max each calendar year.
After the out-of-pocket max is met, the plan covers all eligible in-network services at 100%.
What Can You Do?
To find this information, check your health insurance company's Member Portal or look up your Summary of Benefits and Coverage (SBC). A SBC describes your plan's benefits, costs, restrictions, and exclusions. Look at the Deductible section to see if you've already spent money on it; review the Coinsurance area to determine what percent of charges you'll be responsible for paying; then go to the "Out of Pocket Max" to see how much you can spend on medical expenses before your insurance company begins covering 100% of eligible in-network expenses.
Prior to using an Rx Discount Card for a prescribed medication instead of using your health insurance for coverage, compare the cost difference immediately prior to use and also call your health insurance provider to confirm whether the amount paid using the discount card can be submitted for reimbursement applied toward your deductible or out-of-pocket maximum.
Bottom Line
Your costs for prescriptions may be changing throughout the year regardless of changes to your health insurance. In addition to an annual deductible, your coinsurance (percentage of charges), and your maximum out-of-pocket expense all contribute to how much of your expenses will be paid by your insurance company versus you. Being aware of which phase of your benefits cycle you are currently experiencing, along with the method in which your prescription(s) were obtained (insurance, discount card, etc.), will provide you insight into the amounts being charged and why.
