In the following examples, we will use plan years 2017 to 2018 to illustrate how drug costs can increase year-to-year.
- Your medication is no longer covered by your 2018 drug plan.
If your 2018 prescription drug plan has dropped your medication from the plan’s formulary – possibly due to the availability of a less expensive generic – 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 to have your non-formulary drug covered.
Transition fills are not free and the cost of your transition fill can be more than what you paid for your medication last year. 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 medication, (3) request a formulary exception from your Medicare Part D plan to have a non-formulary drug covered by your plan (click here to learn about requesting a formulary exception), and (4) check the price using a drug discount program.
- You are still
in your plan’s Initial Deductible.
Your 2018 Medicare prescription drug plan may now have an Initial Deductible or a higher Initial Deductible than last year (the 2018 standard deductible is $405), so you are currently paying full price for your medications, until you meet your plan’s deductible. For example, if you were enrolled in the 2017 EnvisionRxPlus (PDP) that had either a $260 or a $270 deductible (depending on your location). Your 2018 Initial Deductible is $300 so you will be in your Initial Deductible longer this year. You can click here to read more about 2017 plans that increased their Initial Deductible in 2018.
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 in a lower-costing formulary tier that is excluded from your plan’s deductible.
- Your drug co-payment increased.
Your Medicare plan may have increased the cost-sharing (co-payment) of your plan’s drug tiers. For example, the Florida AARP MedicareRx Saver Plus plan now has higher cost-sharing on some 2018 drug tiers.
Florida AARP MedicareRx Saver Plus plan 2017 2018 Monthly Premium $32.90 $42.00 Initial Deductible $400 $405 Cost Sharing Tier 1 Preferred Generic $1 $1 Tier 2 Generic $2 $10 Tier 3 Preferred Brand $17 $31 Tier 4 Non- Preferred Brand 30% 36% 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. Also, check the price using a drug discount program.
- Your cost-sharing changed from co-payment to co-insurance.
Your 2018 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 EnvisionRxPlus plan changed their Tier 1 preferred generic drugs from a 10% co-insurance to a $1 co-payment and Tier 2 generics from a 12% co-insurance to $3 copay. So, if the retail price of your Tier 2 medication is less than $25, you will be paying more for your medication in 2018 as compared to 2017.
As an example, AMIODARONE HCL 200 MG TABLET is a low-cost, Tier 2 generic with a flat 2018 $3 co-pay. Last year, you paid $1.03 ($8.56 x 12% co-insurance). If your medication is a more expensive Tier 2 medication, such as PERINDOPRIL ERBUMINE 2 MG TABLET, in 2017 you paid $11.01 ($91.76 x 12%) in co-insurance and in 2018, you only pay the $3 co-pay.
- 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 2018 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.
- Your medication is now on a more expensive formulary tier.
Although you did not change Medicare plans, your plan moved your medication to a higher costing formulary drug tier for 2018. For example, DANAZOL 50MG CAPSULES were a Tier 2 generic medication with $3 co-pay on the 2017 Express Scripts Medicare - Value plan in Texas. Now in 2018, the same medication is a Tier 4 non-preferred drug with 48% co-insurance, bringing your estimated cost-sharing to $78.84 ($164.25 x 48%).
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 should find that 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.
- Your plan uses co-insurance and your drug’s retail price increased.
It is possible that your 2018 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, TERBUTALINE SULFATE 2.5 MG TABLETS on the Texas Cigna-HealthSpring Rx Secure-Extra plan, had a co-pay of $66 ($132 x 50%) in 2017 and this year you are paying $111 ($222 x 50%) – due solely to the 68% increase in drug’s the retail price.
- The retail price of your medications has already pushed you into the Donut Hole.
If the retail price of your medication purchases is already over $3,750, you are in the Coverage Gap (Donut Hole). While in the 2018 Donut Hole you will pay 35% of the retail price for brand-name drugs and 44% of the retail price of generic drugs. You can click here to read more about the Donut Hole or Coverage Gap.
- You have been automatically moved to another Medicare plan.
It is possible your 2017 Medicare plan was consolidated or merged into another drug plan, and you were automatically “crosswalked” (reassigned) to the new plan – and your new Medicare plan may have very different features from your 2017 plan.
Over 80,000 Medicare beneficiaries were crosswalked into a different 2018 Medicare Part D plan, unless they chose a new plan during the Annual Enrollment Period (AEP). For instance, the members of the 2017 First Health Part D Premier Plus plan in 28 states were moved to the 2018 First Health Part D Value Plus plan and now have a Tier 3 preferred brand drug co-payment of $47 instead of the $34 copay they had in 2017. You can click here to read more about other 2017 plans that automatically moved their members to new 2018 Medicare Part D plans.
- 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 (paying your premium, deductible, and lowering 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.
You may have forgotten to submit the required financial documentation for 2018.
Suggestion: Your financial status may have already changed during 2018 and you may, again, be eligible for full Extra Help – 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 https://ssa.gov/prescriptionhelp.
Related Question: I have Extra Help and I didn’t change my Medicare drug plan, so why am I being charged a premium?
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. For example, if you chose to enroll in the 2017 California AARP MedicareRx Saver Plus plan and did not select a new plan during the 2018 Annual Enrollment Period, you still have the same plan for 2018. However, the 2018 AARP MedicareRx Saver Plus plan no longer qualifies for the $0 monthly premium, so you can be charged a portion of the premium. In this case, $8.70 – roughly the difference between the $44.20 plan premium and the 2018 California LIS benchmark premium of $35.51 – the amount you pay is set by the Medicare Part D plan. You can click here to read more.
You can click on the following links to see specific examples of plan changes from past years years:
Increased costs from 2016 to 2017 on this site
Increased costs from 2015 to 2016 on this site
Increased costs from 2014 to 2015 on this site
Increased costs from 2013 to 2014 on this site
Increased costs from 2011 to 2012 on this site