Even if you did not change Medicare plans during the annual
Open Enrollment Period, there are a number of possible reasons why you are
paying more for your prescriptions in 2016.
- Your medication is no longer covered.
If your 2016 prescription drug plan has dropped your medication from the plan’s
formulary, possibly due to the availability of a less expensive generic, and
you have used your 30-day transition
fill, you will now pay full retail cost for your medication. You can
request a formulary exception with your Medicare Part D plan to have a
non-formulary drug covered. Click
here to learn how to request a formulary exception.
-
You purchased your medication at a
non-network pharmacy or a non-preferred network pharmacy. You will pay full
retail at a non-network pharmacy and higher cost-sharing at non-preferred
(standard) network pharmacies. You can 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). Click
here to read more about 2016 preferred and non-preferred pharmacy pricing.
- You are still in your Initial Deductible
phase of coverage. Your 2016 Medicare prescription drug plan may now
have an Initial Deductible or a higher Initial Deductible than last year and
you are paying full price for your medications until you meet your plan’s
deductible. For example, if you are enrolled in the WellCare
Simple plan, your plan follows the standard
deductible model, so your 2016 Initial Deductible has increased $40 from
$320 to $360. If this is the case, your plan coverage will begin once
your prescription drug spending exceeds your deductible and you enter into your
plan’s Initial Coverage Phase. As another example, if you are enrolled in
the Cigna-HealthSpring
Rx Secure-Extra (PDP) you will have a $250 Initial Deductible in 2016 even
though you had no deductible ($0) in 2015. This means you are responsible
for paying the full-retail cost of your medications up to the $250
deductible. You can click
here to read more about other 2015 plans that have added an Initial
Deductible in 2016.
- Your drug co-payments increased.
Your 2016 Medicare plan may have increased the cost-sharing (co-payment) of
your plan’s drug tiers. For example, the Virginia
2015 WellCare Simple plan now has higher cost-sharing on most 2016 drug
tiers.
|
2015
Virginia WellCare Simple
|
2016
Virginia WellCare Simple
|
Monthly Premium
|
$31.90 |
$37.10 |
Initial Deductible
|
$320 |
$360 |
|
Cost
Sharing |
Nbr
of Drugs |
Cost
Sharing |
Nbr
of Drugs |
Tier 1 Cost-Sharing
|
$0
|
289
|
$8
|
323
|
Tier 2 Cost-Sharing
|
$2 |
893 |
$20 |
395 |
Tier 3 Cost-Sharing |
$40 |
896 |
$47 |
866 |
Tier 4 Cost-Sharing |
$88 |
621 |
50% |
771 |
Tier 5 Cost-Sharing
|
25% |
427 |
33% |
446 |
Total Formulary Drugs
|
3,073 |
2,906 |
Read more and see examples in our
article: Why
you may be paying more for your medications in 2016: Increases in your 2016
prescription co-payments or cost-sharing.
- Your cost-sharing changed from co-payment to
co-insurance. Your 2016 drug plan may have changed the cost-sharing
from co-payment (a flat fee) to co-insurance (a percentage of your drug
cost). As seen in the chart above, the WellCare Simple plan changed Tier
4 non-preferred brand-name drugs from an $88 co-payment to a co-insurance of
50%. If the retail price of your medication is more than $176, you will
be paying more for your medication in 2016 as compared to 2015. For
example, Albuterol 4MG tablets are a Tier 4 non-preferred brand and have an
average retail price of $415.07. Using the 2015 co-payment for a Tier 4
medication, you would pay $88. In 2016,
you will pay $207.54 ($415.07 x 50%).
- Your medication is now on a more expensive
formulary tier. Your 2016 plan moved your medication to a higher
costing formulary drug tier. For example, Natacyn Eye Drops were a Tier 3
preferred brand-name medication with $40 co-pay on the 2015 WellCare Simple
plan. Now in 2016, the same medication is a Tier 4 non-preferred brand
drug with 50% co-insurance, bringing your cost-sharing to $150.92
($301.84 x 50%).
As another example, your 2016
Medicare drug plan may have changed the formulary drug tier structure and your
medications may have been re-organized to a higher-costing drug tier. For
instance, the SilverScript
Choice plan in Pennsylvania & West Virginia had one tier for generic
drugs (Tier 1: “Generic”) in 2015 with a co-pay of $7. Now, the 2016
SilverScript Choice plan has added a
new “Preferred Generic” drug tier as Tier 1. So for 2016, Tier 1
Preferred Generics now have a lower co-pay of $3 and the new Tier 2 Generics
have a higher co-pay of $12. You can click
here to see other examples of 2016 Medicare Part D plans with formulary
structure change and the changes in cost-sharing.
- Your medication is now on a lower drug tier
with higher cost. Your 2016 prescription drug plan moved your
medication to a lower drug tier, but the 2016 co-payment is more expensive than
the 2015 co-insurance for the higher drug tier. For example, in 2015 you
had a Tier 4 medication retailing for $100, with a 25% co-insurance (costing
you $25). Now in 2016, the same medication is a Tier 3 medication that
has a $30 co-payment. So although your medication is now on a lower drug tier,
your actual cost-sharing is higher.
- Your plan uses co-insurance and your drug’s
retail price increased. It is possible that your 2016 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 instance, last year you paid
25% of $200 and this year you are paying 25% of $300.
- The retail price of your medications has
already pushed you into the Donut Hole. If the total retail price of
your medications is over $3,310, you will enter the Coverage Gap (Donut Hole)
and pay 45% of the retail price for brand-name drugs and 58% of the retail
price of generic drugs. You
can click here to read more about the Donut Hole or Coverage Gap.
- You have been moved to another Medicare plan.
Your 2016 Medicare plan may have consolidated plans and you were automatically
moved or “crosswalked” to another Medicare Part D plan that has higher
cost-sharing. Over 276,963 Medicare beneficiaries were crosswalked into a
different 2016 Medicare Part D plan, unless they actively chose a new
plan. For instance, if you were enrolled in the 2015
Cigna-HealthSpring Rx Secure-Max plan and did not switch plans, you are now in
the Cigna-HealthSpring Rx Secure-Extra plan. As an example, the Cigna-HealthSpring
Rx Secure-Extra in Alabama & Tennessee, now has a Tier 3 preferred
brand-name medication co-insurance of 20% instead of the $30 co-payment in
2015. Likewise, members now have co-insurance of 43% for Tier 4
non-preferred brand drugs compared to the 2015 co-pay of $85. You can click
here to read more about other 2015 plans that automatically moved their
members to new 2016 Medicare plans.
Please note that the formulary tier changes mentioned above
can be found in your Annual Notice of Change letter (ANOC) or using our PDP-Compare
or MA-Compare
tools or can be found by reviewing your plan’s formulary or using our 2016
Formulary Browser.
If you have a question that we missed, you can click
here and let us know.