Question: The pharmacy called about my new medication, the cost was over $350! Why is this so much?

Let me review a couple of reasons this may be happening.

The first idea I have is that your plan has a deductible. In 2020, there are only three products with no deductible, so most people will have a deductible impact their medication purchases. Many of the insurance products with a deductible waive the deductible rule for medications that are Tier 1 or Tier 2 level. You may have been filling medications up to this point that are Tier 1 or 2 so haven’t noticed this deductible.

This new medication may be a Tier 3, 4 or 5 and therefore the cost is much higher during the deductible. Medicare allows up to a $435 deductible. Most plans have used that as their deductible amount. Some have a different lower figure, like $290, or $360. A deductible means you pay full price for your medication until you have spent that much. Once you move into your initial coverage phase, your insurance company will help to pay for the cost of your medications. During initial coverage your co-pays structure may be something like $14, $47, or $95 or $22.64. This last amount ($22.64) could still be the full cost of the medication because full cost doesn’t get you to the co-pay structure (Tier) that this medication belongs in.

You may have a slightly higher amount to pay next time, because you are finishing up that $435 deductible, then your $350 cost will most likely be reduced to that lower Tier amount for your initial coverage period.

Another situation might be, that your cost of over $350 is because your new medication isn’t covered by the plan you are enrolled in. It is my hope that you looked at the medications you take and evaluated your options for 2020. New medications can’t be predicted. Your company will send you a formulary book, so you and your doctor can look up the medication coverage before you try to fill them. You can call your insurance company to ask about this situation.

We make assumptions that ALL medications are covered the same by ALL insurance. That is NOT the case. Each insurance product makes its own rules for coverage of all the medications available.

Next, what should you do? First, look to make sure the medication is covered. If covered, the cost will go down after your deductible is met. If you can afford that co-pay structure, knowing it will go down to a lower cost in the future, you will fill it now paying more and then once the deductible is met you will feel better. Realize that higher medication costs could put you into the coverage gap later this year.

If your new medication isn’t covered, you can work with your pharmacy & physician to find one that is. You can also review the possibility of switching to an insurance product that does cover this medication. Special Enrollment Periods (SEP’s) may be available that will allow you to switch plans in the middle of the year. These SEP’s can be used to improve your coverage now that you take this medication.

These deductibles are a shock. Just imagine what it is like to be a pharmacist or work at the pharmacy. Many people come to the counter with questions, or need clarification on the cost. We may think the pharmacy made a mistake. Pharmacists have to explain, that it isn’t their fault, it is the plan you chose/have. The insurance plan decides on the coverage rules and the cost you pay. The pharmacy staff gets to to explain WHY it costs over $350.

Be patient and ask questions. Also call your insurance company to give them your feedback on your co-pays. If they know you aren’t happy with this issue, maybe they will consider changing it for 2021. The more feedback they get the better they will understand how we like their products.

Senior Life Matters is a community based program sponsored by Lutheran Jamestown. For questions and concerns or to reach Janell Sluga, GCMC, call us at 716-720-9797 or e-mail at SLM@lutheran-jamestown.org.