Medicare Part D prescription drug plans (PDPs and MAPDs
) can change every year
- even if you didn't change plans and stayed with your same Medicare drug plan from last year - and here are
a few common reasons why you may be paying more for your
prescription coverage this year – along with a few suggestions about
controlling costs even with annual Medicare plan changes.
Your medication is no longer covered by your new Medicare drug plan.
Medicare Part D drug plans usually change their formulary (or drug list) every year. Sometimes a Medicare plan will increase the size of their formulary, adding new drugs - other times you can find that Medicare plans will reduce the size of their drug list, removing drugs, even drugs that you are currently using.
For example, back in 2015, over 10 million
Medicare beneficiaries found at least 100 medications
removed from their plan's 2016 formulary, with some 2016 Medicare plans removing over 1,300 specific medications from the previous 2015 formulary.
As a more-recent example, over 2 million people
enrolled in a 2020 Medicare Part D plan found 100 fewer drugs on their same 2021 Medicare plan.
What to do?
If you find that your Medicare prescription drug plan
dropped your medication from the next-year's plan 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.
Other steps you can take when your drug is no longer covered by your Medicare drug plan.
(1) As noted, request a 30-day transition fill of non-formulary drugs from your plan.
(2) Search for a generic or alternative formulary medication that is covered by your plan.
(3) Request a formulary exception from your plan 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 starts January 1st and continues through March 31st of each year.)
(5) Check to see if any Special Enrollment Periods are available (such as the 5-Star SEP or the low-performing plan SEP or the SEP for people qualifying for Extra Help) - and use the SEP to change to another Medicare plan that provides more complete coverage.
(6) Check your pharmacy for discount programs so you can purchase the non-formulary drug without using your Part D plan or check drug prices using a drug discount program or drug discount card (such as cards available from WellRx.com or GoodRx.com)
Your new Medicare drug plan now has an initial deductible.
Some stand-alone Medicare Part D drug plans (PDPs) and many Medicare Advantage plans that include drug coverage (MAPDs) have a $0 deductible (you receive immediate drug coverage), but deductibles can change year-to year and you may find that your Medicare drug plans now have an initial deductible that you must satisfy before your receive plan coverage.
For example, back in 2014, almost 2 million people
enrolled in a $0 deductible Medicare Part D drug plan would find their 2015 Medicare plan now included an initial drug deductible (of up to $320).
Your plan's drug deductible increased and you are still in your plan’s Initial Deductible phase.
Your new Medicare prescription drug plan may have a higher Initial Deductible than last year (as reference, the 2021 standard deductible is $445
and increases to $480 in 2022).
So, you may be paying retail prices for your medications until meeting
your new plan’s deductible.
For example, if someone was enrolled in the
2019 Texas SilverScript Choice (PDP)
with a $100 deductible, and did not change plans, they would find their 2020 Initial Deductible increased to $360 and would spend more time in the Initial Deductible before plan coverage begins. You can
click here to read more
about 2019 plans that increased their Initial Deductible in 2020.
Be prepared to pay full retail drug costs 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 or Tier 2) that are
excluded from your plan’s deductible
Your plan’s formulary cost-sharing increased.
new Medicare drug plan may have increased the cost-sharing (co-payment or
co-insurance) for your plan’s drug tiers.
, the 2017 Cigna-HealthSpring Rx Secure-Extra (PDP) plan:
- increased the Tier 1 co-pay by $4 (from $1 to $5) and Tier 2 generic drug co-pays by $5 (from $5 to $10);
- changed Tier 3 preferred brands from co-insurance (20%) to co-payment ($42);
- increased the co-insurance on Tier 4 non-preferred brands to 50% (from 29% or 43% depending on the state); and
- increased the co-insurance on Tier 5 Specialty drugs.
As another example, if you were enrolled in the 2020 California Mutual of Omaha Rx Value plan
, you would have found higher cost-sharing on Tier 2 and Tier 3 drugs (e.g., Tier 2 drugs were $5 in 2019 and increased $10 in 2020).
What to do?
|California Mutual of Omaha Rx Value plan
|Tier 1 Preferred Generic
Tier 2 Generic
Tier 3 Preferred Brand
Tier 4 Non- Preferred Brand
Tier 5 Specialty Tier
If your formulary cost-sharing increases for a particular drug , you can request a tiering exception
from your Medicare Part D plan to have your medication moved to a more affordable drug tier. Please remember that a tiering exception may not be available to lower the cost of more-expensive Specialty Tier drugs when a lower-tier equivalent drug is not available - check your plan's documentation for more information.
Your formulary cost-sharing structure changed from co-insurance to a fixed co-payment.
Your new 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 2019 Humana Walmart Rx plan
changed the Tier 3 preferred brand drugs from 20% co-insurance to a $42 co-payment when it became the 2020 Humana Premier Rx plan
So, in this example, if the retail price of a Tier 3 medication was less than $210,
you would pay 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
. In 2019, you would have paid approximately $10 ($46.10 x 20% co-insurance
) for the same drug. (However on the positive side, 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 paid the $42 co-pay
Your new plan still uses the co-insurance rates, but now your plan's negotiated retail drug price increased.
It is possible that your new 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.
As an example, refer to the above 2020 California Mutual of Omaha Rx Value plan
that did not change Tier 4 Non-Preferred Brand cost-insurance from year-to-year. So in 2020, you paid 48% of retail for your Tier 4 drugs, the same 48% as you paid in 2019. However, since retail drug prices can change at any time (even week-to-week), you may be paying more for Tier 4 drugs when the retail cost of your drugs increases.
Your medication is now on a more expensive formulary tier.
Although you did not change Medicare Part D plans, your new Medicare drug 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
($507.61 x 44%).
Request a tiering exception
from your Medicare Part D plan to have your medication moved to a more affordable drug tier.
You can ask your plan for a formulary exception to either 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.
Related Question: Can I get a tiering exception to lower the cost of my Tier 5 Specialty Drug.
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
Consider checking your drug’s price using a drug discount program
total retail price of your medications has already pushed you into the
Donut Hole – where you may be paying higher cost-sharing (even with the Donut Hole Discount).
If the total retail cost of your medication purchases is already over your plan's Initial Coverage Limit ($4,130
in 2021, increasing to $4,430 in 2022), you are in the Coverage Gap (Donut Hole) and even with the 75% Donut Hole Discount
on all formulary drugs,
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
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. For example, you can click here to read more about cost-sharing at preferred and standard network pharmacies
For the lowest cost-sharing costs, 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
Each year, Medicare Part D plans are permitted to automatically move plan members
You have been automatically "moved" to another, more-expensive Medicare drug plan.
to another Medicare drug plan for the next year. So, if your drug costs (and/or coverage) have changed, it is possible that your Medicare plan from last year was consolidated or merged into another drug
plan, and you were automatically “crosswalked” (reassigned) to the new
plan – and you may have very different features (drug costs, drug coverage, monthly premium, deductible) in your "new" Medicare drug plan
as compared to your plan from the previous year.
For example, over 4.4 million people
- 3.2 million people enrolled in 2021 stand-alone Medicare Part D plans and an additional 1.2 million enrolled in 2021 Medicare Advantage plans - were scheduled to be automatically moved into a different 2022 Medicare plan - unless these people chose another Medicare plan themselves.
From 2019, 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
) and now have Tier 3 Preferred Brand drugs covered with $47 copayment instead of the $40 copayment they had in 2019.
As another example, members
of the 2019 Humana-Walmart Medicare Part D drug plan who did not change their plan during
the annual Open Enrollment Period would find themselves automatically moved to the 2020 Humana
Preferred plan with a monthly premium increase of over 100% and changes
in cost-sharing for formulary Tier 3 and Tier 4.
click here for more examples
about plans that automatically moved their members to new 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 (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
required this year and your Extra Help benefits were not continued.
The Extra Help eligibility limits
(based on the Federal Poverty Level guidelines) change each year 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 https://www.ssa.gov/benefits/medicare/prescriptionhelp/
- You still qualify for Medicare Part D Extra Help benefits,
but you now are paying a premium for your Part D plan.
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
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
new 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
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.