- Your medication is no longer covered by your 2020 drug plan.
If your 2020 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 (MA or MAPD), you can use the Medicare Advantage Open Enrollment Period ( MA-OEP) to switch to a plan ( PDP or MAPD) that covers your drugs (the MA-OEP runs through March 31st), and (5) check the drug price using a drug discount program.
Reminder: You can ask your plan to cover a non-formulary drug or ask your plan to move a formulary drug to a lower costing tier, but you cannot ask your plan to cover a non-formulary drug and then ask for a tiering exception to lower the cost of the drug.
- You are still in your plan’s Initial Deductible.
Your 2020 Medicare prescription drug plan may have a higher Initial Deductible than last year (as reference, the 2020 standard deductible is $435). So you may be paying full price for your medications, until you meet your 2020 plan’s deductible. For example, if you were enrolled in the 2019 Texas SilverScript Choice (PDP) that had a $100 deductible, your 2020 Initial Deductible is now $360, so you will be in your Initial Deductible longer this year. You can click here to read more about 2019 plans that increased their Initial Deductible in 2020.
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 (such as Tier 1) that is excluded from your plan’s deductible.
- Your 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 California Mutual of Omaha Rx Value plan, you will find higher cost-sharing on two 2020 drug tiers, for example Tier 2 drugs were $5 in 2019 and now $10 in 2020.
California Mutual of Omaha Rx Value plan
2019 2020 Monthly Premium $43.30 $51.70 Initial Deductible $415 $435
Cost Sharing Tier 1 Preferred Generic $3 $0 Tier 2 Generic $5 $10 Tier 3 Preferred Brand $34 $42 Tier 4 Non- Preferred Brand 48% 48% Tier 5 Specialty Tier 25% 25%
Suggestion: Request a tiering exception from your Medicare Part D plan to have your medication moved to a more affordable drug tier.
- Your cost-sharing changed from co-insurance to a fixed co-payment.
Your 2020 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 instance, the Humana Walmart Rx plan changed their Tier 3 preferred brand drugs from 20% co-insurance to a $42 co-payment when it became the 2020 Humana Premier Rx plan. So, if the retail price of your Tier 3 medication is less than $210, you will be paying more for your medication in 2020 with the $42 fixed co-pay as compared to the 2019 co-insurance of 20%.
As an example, Betaxolol 5 MG/ML Ophthalmic Solution is a low-costing, Tier 3 preferred brand with a 2020 $42 co-pay. Last year, you would have paid approximately $10 ($46.10 x 20% 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 2019 you paid approximately $109 ($544.57 x 20%) in co-insurance and in 2020, you only pay the $42 co-pay.
- Your 2020 plan uses co-insurance and your drug’s retail price increased.
It is possible that your 2020 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 (you pay a percent of the retail drug cost) as their cost-sharing model.
- Your medication is now on a more expensive formulary tier.
Although you did not change Medicare Part D plans, your 2020 plan moved your medication to a higher costing formulary drug tier.
For example, ALBUTEROL SULFATE 2 MG was a Tier 1 preferred generic medication with $1 co-pay on the 2019 Humana Walmart Rx Plan in Pennsylvania. Now in 2020, your plan name changed to the Humana Premier Rx plan and the same medication is a Tier 4 non-preferred drug with 44% co-insurance, bringing your estimated cost-sharing to $223.35 ($507.61 x 44%).
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.
No. You may find that your Medicare Part D plan’s Evidence of Coverage (EOC) document states something like: “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”.
Suggestion: Consider checking your drug’s price using a drug discount program.
- 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 already over $4,020, you are in the 2020 Coverage Gap (Donut Hole) and even with the 75% Donut Hole Discount, your cost-sharing may be higher than what you paid in your Initial Coverage Phase. While in the Donut Hole you will pay 25% of the retail price for all formulary drugs – and this may be more than what you paid in the earlier part of your plan. You can click here to read more about cost changes when entering the Donut Hole or Coverage Gap.
- 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 also pay higher cost-sharing. Click here to read more about cost-sharing at 2020 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 in an emergency and ask your Medicare plan for reimbursement.
- You have been moved to another, more-expensive Medicare drug plan.
If your 2019 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 2020 Medicare plan compared to your 2019 plan.
For example, over 55,000 members of the 2019 WellCare Extra plan were moved to the 2020 WellCare Medicare Rx Value Plus plan (unless they actively chose a different plan during the AEP) and now have Tier 3 Preferred Brand drugs covered with $47 copayment instead of the $40 copayment they had in 2019. You can click here to read more about other 2019 plans that automatically moved their members to new 2020 Medicare Part D plans.
Members of the 2019 Humana-Walmart plan who did not change their plan during the annual Open Enrollment Period now will find themselves in the Humana Preferred plan with a monthly premium increase of over 100% and changes in cost-sharing for formulary Tier 3 and Tier 4.
- 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 with partial benefits 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 2020 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 2020, 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 ssa.gov/prescriptionhelp.
- 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 Part D 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 monthly 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.
- If you are a higher-earning Medicare beneficiary, you may now be paying the
2020 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.