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 3.8 million people enrolled in a 2022 Medicare Part D plan found 100 fewer drugs on their same 2023 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.

Remember:  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 2023 standard deductible is $505 and $545 in 2024).  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.  For more recent examples of annual changes in initial deductibles, you can click here to read more about 2022 Medicare Part D plans that increased the plan's initial deductible in 2023.

Suggestion:  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.

Your new Medicare drug plan may have increased the cost-sharing (copayment or coinsurance) for your plan’s drug tiers.

For example, back in, the 2017 Cigna-HealthSpring Rx Secure-Extra (PDP) plan:

• increased the Tier 1 copay by $4 (from $1 to $5) and Tier 2 generic drug copays by $5 (from $5 to $10);
• changed Tier 3 preferred brands from coinsurance (20%) to copayment ($42);
• increased the coinsurance on Tier 4 non-preferred brands to 50% (from 29% or 43% depending on the state); and
• increased the coinsurance 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).


For more recent examples of annual cost-sharing changes, you can click here to read more about 2022 Medicare Part D plans that increased the plan's cost-sharing structure in 2023.

What to do?
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 coinsurance to a fixed copayment.

Your new drug plan may have changed your cost-sharing from coinsurance (a percentage of your drug’s retail price) to copayment (a flat fee) or vise-versa.  For instance, the 2019 Humana Walmart Rx plan changed the Tier 3 preferred brand drugs from 20% coinsurance to a $42 copayment 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 copay as compared to the 2019 coinsurance of 20%.  As an example, Betaxolol 5 MG/ML Ophthalmic Solution is a low-costing, Tier 3 preferred brand with a 2020 $42 copay.  In 2019, you would have paid approximately $10 ($46.10 x 20% coinsurance) 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 coinsurance and in 2020, you only paid the $42 copay.)

• Your new plan still uses the coinsurance 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 coinsurance (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.

As an example, ALBUTEROL SULFATE 2 MG was a Tier 1 preferred generic medication with $1 copay 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% coinsurance, bringing your estimated cost-sharing to $223.35 ($507.61 x 44%).

Suggestion:  Request a tiering exception from your Medicare Part D plan to have your medication moved to a more affordable drug tier.

Reminder: 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.

No.  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 tier”.

Suggestion:  Consider checking your drug’s price using a drug discount program.

• The 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 ($4,660 in 2023, increasing to $5,030 in 2024), 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 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 also pay higher cost-sharing.  For example, you can click here to read more about cost-sharing at preferred and standard network pharmacies.

Suggestion:  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).

Can't find a standard or preferred network pharmacy in your area?
If you cannot find one of your Medicare Part D plan's 50,000 to 65,000+ network pharmacies (for example, you are traveling in a remote area), you may be able to use a non-network pharmacy in an emergency and ask your Medicare plan for reimbursement.

• You have been automatically "moved" to another, more-expensive Medicare drug plan.

Each year, Medicare Part D plans are permitted to automatically move plan members 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 1.4 million people - 1.26 million enrolled in 2022 Medicare Advantage plans and an additional 200,000 people enrolled in a 2022 stand-alone Medicare Part D plan - are scheduled to be automatically moved into a different 2023 Medicare plan - unless these people chose another Medicare plan themselves.

As an older example, back in 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 the AEP) 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.

You can 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.

Suggestion:  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.

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 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.

Suggestion:  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 (IRMAA) 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.

For year-related examples of how your Medicare Part D drug costs can change  . . . you can click on the following links to see specific examples of plan changes from past years:

Examples of increased Medicare plan costs when moving from year to year:

Increased costs from 2020 to 2021: Q1News.com/890
Increased costs from 2019 to 2020: Q1News.com/806
Increased costs from 2018 to 2019: Q1News.com/512
Increased costs from 2017 to 2018: Q1News.com/408
Increased costs from 2016 to 2017: Q1News.com/318
Increased costs from 2015 to 2016: Q1News.com/410
Increased costs from 2014 to 2015: Q1News.com/437
Increased costs from 2013 to 2014: Q1News.com/328
Increased costs from 2011 to 2012: Q1News.com/190