Here are a few examples of why you may be paying more this year for your Medicare prescription coverage – and a few suggestions about controlling costs.
Question: I didn’t change my Medicare drug plan this year, so why am I paying more for my prescriptions?
- 1. Your medication is no longer covered by your 2019
drug plan.
If your 2019 prescription drug plan dropped your medication from the plan’s formulary – possibly due to the availability of a less-expensive generic drug – your plan will provide you with a 30-day transition fill so you have time to find an alternative medication or file a formulary exception request asking for coverage of your non-formulary drug.
Transition fills are not free and the cost of your transition fill can be more than what you paid for your medication last year. In addition, if you have not requested a transition fill, or already used your 30-day transition fill, you will pay the full retail cost for your non-formulary medication.
Suggestions: (1) Request a transition fill, (2) search for a generic or alternative formulary medication, (3) request a formulary exception for coverage of a non-formulary drug (click here to learn about requesting a formulary exception), (4) if you are enrolled in a Medicare Advantage plan that includes drug coverage (MAPD), you can use the Medicare Advantage Open Enrollment Period (MA-OEP) to switch to another MAPD that covers your drugs (through March 31st), and (5) check the drug price using a drug discount program.
- 2. You are still in your plan’s Initial Deductible.
Your 2019 Medicare prescription drug plan has a higher Initial Deductible than last year (as reference, the 2019 standard deductible is $415). So you may be paying full price for your medications, until you meet your 2019 plan’s deductible. For example, if you were enrolled in the 2018 North Carolina EnvisionRxPlus (PDP) that had a $300 deductible, your 2019 Initial Deductible is now $365, so you will be in your Initial Deductible longer this year. You can click here to read more about 2018 plans that increased their Initial Deductible in 2019.
Suggestion: Be prepared to pay full retail cost until you meet your plan’s deductible or, depending on your plan, seek generic drugs that may be on a lower-costing formulary drug tier that is excluded from your plan’s deductible.
- 3. Your 2019 plan's cost-sharing increased.
Your Medicare drug plan may have increased the cost-sharing (co-payment or co-insurance) for your plan’s drug tiers. For example, if you are enrolled in the Illinois SilverScript Choice plan, you will find higher cost-sharing on most 2019 drug tiers.
Illinois SilverScript Choice plan
2018 2019 Monthly Premium $23.40 $26.80 Initial Deductible $0 $0
Cost Sharing Tier 1: Preferred Generic $3 $9 Tier 2: Generic $17 $19 Tier 3: Preferred Brand $44 $46 Tier 4: Non- Preferred Brand 48% 49% Tier 5: Specialty Tier 33% 33%
Suggestion:Request a tiering exception from your Medicare Part D plan to have your medication moved to a more affordable drug tier.
- 4. Your 2019 cost-sharing changed from co-insurance to a fixed co-payment.
Your 2019 drug plan may have changed your cost-sharing from co-insurance (a percentage of your drug’s retail price) to co-payment (a flat fee) or vise-versa. For example, the EnvisionRxPlus plan changed their Tier 3 preferred brand drugs from a 15% co-insurance to a $29 co-payment. So, if the retail price of your Tier 3 medication is less than $194, you will be paying more for your medication in 2019 as compared to 2018.
For instance, ACETAZOLAMIDE 250MG TABLET is a low-costing, Tier 3 preferred brand with a 2019 $29 co-pay. Last year, you paid approximately $12 ($79.58 x 15% co-insurance) for the same drug. However, if your medication is a more expensive Tier 3 medication, such as ADVAIR DISKUS MIS 500/50, in 2018 you paid approximately $163 ($1,084.43 x 15%) in co-insurance and in 2019, you only pay the $29 co-pay.
- 5. Your 2019 plan uses
co-insurance and your drug’s retail price increased.
It is possible that your 2019 Medicare prescription drug plan did not make any changes in cost-sharing or formulary structure, but your Medicare Part D plan’s negotiated retail cost for your medication has increased and you are paying more because your plan uses co-insurance as a cost-sharing model.
For example, Banzel 40mg/mL on the Texas Aetna Medicare Rx Select plan, had a co-insurance of $371.70 ($1,486.80 x 25%) in 2018 and this year, you are paying $407.76 ($1,568.29 x 26%) – due not only to the small increase in co-insurance rates, but also the increase in drug’s the retail price.
- 6. Your
medication is now on a more expensive formulary tier.
Although you did not change Medicare Part D plans, your 2019 plan moved your medication to a higher costing formulary drug tier.
For example, Hydrocodone/Acetaminophen 300-5 was a Tier 3 preferred brand medication with $42 co-pay on the 2018 Cigna-HealthSpring Rx Secure-Extra plan in California. Now in 2019, the same medication is a Tier 4 non-preferred drug with 49% co-insurance, bringing your estimated cost-sharing to $67.84 ($138.45 x 49%).
Suggestion: Request a tiering exception from your Medicare Part D plan to have your medication moved to a more affordable drug tier.
Related Question: Can I get a tiering exception to lower the cost of my Tier 5 Specialty Drug?
Probably not. Your Medicare Part D plan Evidence of Coverage (EOC) document states: “Drugs of our [insert name of specialty tier] are not eligible for this type of exception [tiering exception]. We do not lower the cost-sharing amount for drugs in this tier”. However, Medicare Part D plans that have only one drug tier or use the standard cost-sharing (25%) across all tiers may exclude the above text from their EOC.
Suggestion: Consider contacting the drug manufacturer and ask about a Patient Assistance Program or other means to receive a discounted price. Also, check the price using a drug discount program.
- 7. The total
retail price of your medications has already pushed you into the Donut Hole –
where you may be paying higher cost-sharing.
If the total retail cost of your medication purchases is over $3,820, you are already in the 2019 Coverage Gap (Donut Hole) and your cost-sharing may be higher. While in the Donut Hole you will pay 25% of the retail price for brand-name drugs and 37% of the retail price of generic drugs - but even with the Donut Hole Discount, you may pay more for a prescription in the Coverage Gap. You can click here to read more about the Donut Hole or Coverage Gap.
- 8. You purchased
your formulary medication at a non-network pharmacy or a standard network
pharmacy.
If you fill a prescription at a pharmacy that is not part of your Medicare Part D plan’s pharmacy network, you will pay full retail price for the medication. If you fill a prescription at a pharmacy that is considered a standard network pharmacy, rather than a preferred network pharmacy, you may pay higher cost-sharing. Click here to read more about cost-sharing at 2019 preferred and standard network pharmacies.
Suggestion: Contact your plan’s Member Services department to find a preferred network pharmacy in your area (or to learn about mail-order options, if available). If you cannot find a network pharmacy, you may be able to use a non-network pharmacy and ask your Medicare plan for reimbursement.
- 9. You have been
moved to another, more-expensive 2019 Medicare drug plan.
If your 2018 Medicare plan was consolidated or merged into another drug plan, and you were automatically “crosswalked” (reassigned) to the new plan – you may have very different features in your 2019 Medicare plan compared to your 2018 plan.
For example, over 735,000 members of the 2018 Symphonix Value Rx plan were moved to the 2019 AARP MedicareRx Saver Plus plan (unless they actively chose a different plan during the AEP) and now have Tier 4 non-preferred drugs covered with 31% co-insurance instead of the 25% co-insurance they had in 2018. You can click here to read more about other 2018 plans that automatically moved their members to new 2019 Medicare Part D plans.
- 10. You have lost
(or had a change in) your Medicare Part D Extra Help benefits.
If your financial situation has changed, it is possible that you are no longer eligible for Medicare Part D Extra Help benefits (that pay your premium, deductible, and lower your drug cost-sharing) – or you may have been moved to an Extra Help level that is less than the full (or 100%) Low-Income Subsidy and are now paying a portion of your deductible and higher drug costs.
Alternatively, you may have forgotten to submit the required financial documentation for 2019 and your Extra Help benefits were not continued this year.
Suggestion: The Extra Help eligibility limits were recently increased and you may now qualify for the Low-Income Subsidy. Or, if your financial status has already changed during 2019, you may be eligible for full Extra Help again – or you may be eligible for a higher level of support. Contact your local state Medicaid office for more information about your Extra Help status or visit http://ssa.gov/prescriptionhelp.
- 11. You still
qualify for Medicare Part D Extra Help benefits, but now are paying a premium
for your Part D plan.
If a Medicare Part D plan no longer qualifies for the full Low-Income Subsidy (LIS) $0 monthly premium, Medicare will automatically move LIS recipients to a new plan that does qualify. However, if you selected your own plan, Medicare will not move you to a new plan, even if your plan no longer qualifies for the $0 premium – and you will pay a partial premium. You can click here to read more.
Suggestion: Extra Help beneficiaries can use the Dual Eligible Special Enrollment Period to change Medicare Part D plans once per quarter, so you can change your Medicare Part D coverage to a plan that meets the $0 premium and still covers all of your medications.
- 12. If you are a higher-earning Medicare beneficiary, you may now be paying the 2019 Income-Related Monthly Adjustment Amount (IRMAA) in addition to your monthly Medicare plan premium.
If your annual income (MAGI) exceeds certain limits - and you are enrolled in a stand-alone Medicare Part D plan (PDP) or a Medicare Advantage plan that includes prescription drug coverage (MAPD), then you can be charged an Income-Related Monthly Adjustment Amount (IRMAA) for your Medicare Part D (and, if applicable, your Medicare Part B coverage). You can browse our IRMAA FAQs to learn more. Also, even if you are enrolled in an employer health plan that offers creditable prescription drug coverage, you can be charged IRMAA for your drug coverage and Medicare Part B coverage.