I did not change my Medicare Part D prescription drug plan during the Annual Enrollment Period and have the same Medicare prescription drug plan as in 2013.  But  now one of my prescriptions that cost me $2.50 in December is now costing me $10 in 2014.  Why am I paying more for the same medication this year?

There are a number of possible reasons why you are paying more for your medication in 2014:

1.    Your 2014 Medicare plan may have raised the cost-sharing (co-payment) rates on the plan’s drug tiers.  For instance, if you enrolled in the First Health Part D Value Plus plan in California, a 2014 Tier 1 “Preferred Generic” medication now has a $3 co-payment instead of the $0 co-payment you had in 2013.

 2.  Your 2014 Medicare prescription drug plan may now have an initial deductible and you may be paying full price for your medications until meeting your deductible.  If this is the case, you will go into your plan’s Initial Coverage Phase once you spend more than your deductible.  For example, if you are enrolled in the Alliance Medicare Rx plan you will have a $75 initial deductible in 2014 even though you had no deductible ($0) in 2013.

3.  Your Medicare drug plan has changed its formulary drug tier structure for 2014.  For instance, your 2014 plan may have changed it formulary from 4 drug-tiers to 5 drug-tiers.  So you may find that your 2013 “Generic” medications are now 2014 “Non-Preferred Generics” and have higher co-payments.  As an example, the WellCare Classic plan had one tier for generic drugs (Tier 1: “Preferred Generic”) in 2013 with a co-pay of $7.  Now, the 2014 WellCare Classic plan has added a new Tier 2 “Non-Preferred Generic” drug tier.  So for 2014, Tier 1 Preferred Generics now have a co-pay of $0 and the new Tier 2 Non-Preferred Generics have a co-pay of $15.  You can click here to read more about the structure of the 2014 formulary tiers.

4.  Your 2014 plan has moved your medication to a higher costing tier on its formulary (drug list) or your plan has moved your medication to lower tier, but the cost-sharing is now more than the 2013 co-insurance on the higher drug tier.  For instance, you may have had a medication that retails for $100 and in 2013 it was a Tier 4 medication with 25% co-insurance (costing you $25).  Now in 2014, the same medication may be a Tier 3 medication that has a $40 co-payment.

5.  Your 2014 plan may have changed the drug tier cost-sharing from co-insurance of 25% to a co-payment.  As an example, The EnvisionRxPlus Silver plan changed Tier 1 from a 25% co-insurance to a co-payment of $10 in many states.  If your medication has a retail price of less than $40, you will be paying more for your medication in 2014. Simvastatin has a retail price of $10.15.  In 2013 you would have paid $2.54 ($10 x 25%) in 2014, you will pay $10 – the flat co-pay for a Tier 1 drug.

6.  Your 2014 prescription drug plan has dropped your medication from the plan’s formulary (possibly due to the availability of less expensive generic alternatives) and you are now paying full retail cost for your medication.  Click here to learn how to request a formulary exception.

7.  You purchased your medication at a pharmacy that is a non-preferred network pharmacy or a non-network pharmacy.  You can read more about non-preferred network pharmacies below in this Newsletter’s next question and you can click here for an example of preferred vs non-preferred network pharmacy cost-sharing.

Please note that the formulary tier changes mentioned above can be found in your Annual Notice of Change Letter (or using our PDP-Compare  or MA-Compare tools) or can be found by reviewing your plan’s formulary or using our 2014 Formulary Browser.