I have the same Medicare drug plan as last year, so why am I paying more for my 2016 medications?

• 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. 

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.