November 28, 2023

Question: I went to pick up my medication and it cost $154.26, last time it was $42. What happened and why does it cost so much more?

Answer: Each insurance company handles Prescription co-pays differently and their policies can change from year to year. So even if you didn’t change your prescription drug coverage for 2022, your coverage in fact may be very different.

There are some universal rules that apply to coverage. Each company defines their Formulary, the list of medications covered by the plan, and will help pay for. No plan covers all drugs on the market, so each formulary is a little different. The formulary may cover different medications with different co-pay amounts.

Medicare Prescription Drug coverage does exclude categories of medications such as; Barbiturates, Benzodiazepines, medications used for anorexia, weight loss/gain, fertility, hair growth, cold symptoms, most vitamins and over the counter medications.

Insurance companies decide which medications to include in their formulary, they also decide how they will cover those medications. This is the “tiering” of the medications. The medications covered by your insurance company are grouped into tiers, and your co-payment is determined by the tier that your medication is in. Insurance plans have typically five or six tiers. Your prescription drug plan places each medication it covers in a tier and different rules apply to the different tiers.

Briefly the two types of medications that make up the tiers are Brand Name and Generic Medication.

A Brand Name drug is a medication sold by a pharmaceutical company under a trademark-protected name. Brand name medications can only be produced and sold by the company that holds the patent for the drug. Brand name medications are available by prescription and over the counter (example; Eliquis or Zyrtec). An example is Synthroid; Synthroid (prescribed as a brand name), costs most people with Part D plans between $30 and $45 per month for the medication. Synthroid is available as a generic named Levothyroxine. If you get the generic Levothyroxine it may cost $0 to $12 per month. That is a significant difference.

A Generic medication is available when the patent of a brand name medication expires. This means other companies can produce a generic version of that name brand medication. The Generic version of the drug must use the same active ingredients as the brand name, and it must meet the same quality and safety standards as the brand name drug. The additives and dyes can be different, so it does not look the same and is not exactly the same as the Brand Name.

During the coverage gap (Donut Hole), medication becomes 25% of the retail cost. Using Synthroid and Levothyroxine that pricing at 25% is very different. Synthroid costs approximately $48 for a 30 day supply, so 25% becomes $12 per month. Levothyroxine costs approximately $7 for a 30 day supply, so 25% becomes $1.75 per month. In this example the difference is small, but there may be significant differences to the consumer depending on the medication. The Example of Advair ($425 per month) as 25% becomes $106. The Generic Fluticasone/Salmeterol ($75) as 25% becomes $18.75.

I am using Synthroid and Advair as examples because your cost share is different in the initial coverage phase due to tiering of medications. In the coverage gap the cost difference is based on the retail cost of the medication. Therefore, you need to look at your plan and how it covers your medications each year. You should not assume that your co-pays will be the same year to year or during the year.

I often hear from individuals after they have returned home from the Pharmacy. They are shocked and angry that their medications cost different amounts than they did last year or just last time. Your company sent you information indicating how your costs were going to change called Annual Notice of Change around October 1st last year. Look at that material now and see if what is happening to you is described in the material you were sent. If you feel it is NOT reflected in the material you were sent, call the insurance company. You can ask questions, you can ask for exceptions, you can talk to your doctor about a different medication all together.

The more you know, the more you can fight for your rights!

Senior Life Matters is a community based program sponsored by Lutheran Jamestown. For questions and concerns or to reach Janell Sluga, GCMC, call 716-720-9797 or email [email protected].

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