- You could be in the deductible phase of your Medicare Part D coverage and you are responsible for 100% of your drug costs during this phase unless your plan offers coverage for select medications. Many Medicare Part D prescription drug plans exclude low-costing Tier 1 and Tier 2 medications from the initial deductible (so you get coverage for these low-cost drugs before meeting your deductible), but even with such a situation, it is possible that your generic medication is placed on Tier 3 of the formulary - and be subject to the initial deductible.
- Your generic medication may be so inexpensive that it costs less than your copay (especially if you are visiting a standard network pharmacy - and not a preferred network pharmacy. For example, your Tier 1 drug may have a retail cost of $6 and the standard network pharmacy co-pay is $11. You will never pay more than retail, so you will pay the full $6 cost and not the $11 co-pay.
- It is possibility that your generic medication is not on your plan's formulary - so your drug is not covered by your Medicare Part D plan and you are being charged full retail costs.
- You can review your plan's formulary at on this site to see if your medication (or a similar medication) is covered by your Medicare Part D plan
- You can ask your plan for a formulary exception. Learn more at on this site AppealComplaint.php
- You can review your plan's formulary at on this site to see if your medication (or a similar medication) is covered by your Medicare Part D plan
- It could be that your generic requires prior authorization from your Medicare Part D plan before the prescription can be filled and you did not get the required authorization.
- It could be that your generic medication has quantity limits (such as 30 pills for 30 days) and you have exceeded those limits.
You monthly Explanation of Benefits document may give you some additional insights as to why you are paying full prices.
We offer some help in understanding the explanation of benefits on this site.