Question: Why was my new medication more than $350?

Answer: 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 you may not have 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 $435 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 the full amount of the deductible. 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, $95 or $22.64. This last amount, $22.64, may still be the full cost of the medication because full cost doesn’t get you to the co-pay structure (Tier) in which your medication belongs.

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

Another scenario might be that your medication cost of over $350 is because your new medication isn’t covered by the plan in which you are enrolled. Hopefully 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 medications coverage before you try to fill any. You can call your insurance company to ask about this situation.

We may think that all medications are covered the same by all insurance providers. That is not the case. Each insurance provider makes its own rules for coverage of all the medications available.

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. 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 and 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 (SEPs) may be available that will allow you to switch plans in the middle of the year. These SEPs can be used to improve your coverage now that you take a new medication.

These deductibles can be a shock. 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. Pharmacists have to explain that it is the plan you chose. The insurance plan gives coverage rules and the cost you pay. The pharmacy staff gets to to explain why it costs more than $350.

Be patient and ask questions. Also call your insurance company representatives 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 their products how their products are liked.

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