Unexpected Prescription Costs

Were you surprised when you visited the pharmacy to pickup a prescription only to discover the drug is either not covered by your plan, or the cost has jumped?   Why is that and what can you do?

Possible Causes

    • Your plan may have a prescription drug deductible, and the deductible must be paid first. This cost often occurs in January or whenever a patient fills a prescription for a brand-name drug.  In 2020, Medicare allows prescription deductibles of up to $435 per year.
    • The pricing tier level or the tier co-pay for your drug may have changed.  Plans offering prescription drug coverage place drugs into different “tiers” on their formularies. Each plan can divide its tiers in different ways with each tier having a different co-pay amount. Generally, a drug in a lower tier (for example, Tier 1) will cost you less than a drug in a higher tier (for example, Tier 3). Most plans have at least 5 tiers; the higher the tier number the higher the co-pay.
    • Your drug may have been removed from the formularyMost Medicare drug plans have their own list of what drugs are covered, called a formulary.  This list typically includes generic drugs as well as brand-name drugs.  The formulary may or may not include your specific drug.Drug plans offering Medicare prescription drug coverage (Part D) that meet certain requirements can immediately remove brand name drugs from their formularies and replace them with new generic drugs, or they can change the cost or coverage rules for brand name drugs when adding new generic drugs.

For changes involving a drug you’re currently taking that will affect you during the year, your plan must do one of these:

        • Give you written notice at least 30 days before the date the change becomes effective.
        • At the time you request a refill, provide written notice of the change and at least a month’s supply under the same plan rules as before the change.

Steps to Take

Here are steps you can take to obtain the prescription coverage you need:

    • Talk to your doctor to see if you can use a different prescription drug on the formulary or a drug with a lower pricing tier.
    • Have your doctor submit an Exception Request to the plan if:
        • Your prescriber believes you need a drug that isn’t on your plan’s formulary.
        • Your prescriber believes that a coverage rule (like prior authorization) should be waived.
        • You think you should pay less for a higher tier (more expensive) drug because you or your prescriber believes you can’t take any of the lower tier (less expensive) drugs for the same condition.
        • You disagree with your plan’s “at-risk determination” under a drug management program that limits your access to coverage for frequently abused drugs.
    • Contact us to find out if there is a plan offering coverage of all your prescription drugs and to determine if you qualify for a special enrollment period or if the Open Enrollment Period (January 1 – March 31) or the Annual Enrollment Period (October 15 – December 7) are available for you.

Clear as Mud?

We understand the terminology, processes and timing are confusing, so talk to us about your situation and we will review your options with you and determine if you qualify for an enrollment period.



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