Question: I went to pick up my new medication, and it was over $250. My medications have always been free. Why didn’t my insurance pay for this medication?

Answer: Your question is interesting and I have a good idea what is happening. I see two common reasons for this “sticker shock” when starting a new medication, and I’ll run through both scenarios with you. It’s important to remember that all medications cost money, but what can change is how much you pay versus how much your insurance pays.

One possibility is that up to this point, you have taken mostly generic medications, and your plan has likely considered them ‘preferred generics” which places them in a low “Tier”, and that Tier deemed your cost share to be $0.

Your insurance plan also has a deductible for medications. The deductible for your medication can be as much as $615 this year. When your medications are preferred generics, your insurance plan waived the deductible for those preferred generic medications. In this instance, you haven’t paid anything for your medications, because they have all been a $0 copay to you. That’s excellent news for the generic medications you’ve been taking, but at the same time, this means haven’t made any progress toward meeting your plan’s deductible.

Now if you are being billed $250 for this new medication, it’s likely that this medication is NOT generic, and therefore you will have to pay some money for it. When medication is not in the Tier that is ‘preferred generic’, you will have to pay full price until you have met the deductible.

If that new medication costs $250 per month, and your deductible is the maximum $615, then you would have to pay full price for the first two months ($250 + $250), to work your way through the deductible. The third month you go to pick the medication up, you will likely see a cost reduction — you will finish up the deductible ($615-$500 = $115) and then you will pay the cost share for that Tier. If the cost share at that Tier is, say, 25%, then that would be $62.50. So your third month could be as much as $115 + $62.50 = $177.50. Then, every month after that, for the remainder of the year, your monthly cost for that medication would be $62.50. This is still more than you’re used to, but the coverage is an improvement compared to the full $250.

A second possible scenario is that the new medication is in fact NOT covered by your insurance plan. I believe that if that was the case, the pharmacists would have told you that. Then they usually offer to find an alternative medication that is covered, or the pharmacist would recommend you speak with your physician to find an alternative medication.

In this scenario, I would recommend working with the pharmacist and your physician to find alternative medication. If your insurance does not cover your medication, you would have to pay full price, $250, every time you go to refill that medication, all year long. If you ask me, it does not make sense to do that. The reason you carry insurance is to help reduce the cost of your medications and your medical care. So I don’t believe it makes sense to pay full price for medications that aren’t covered.

If this medication is very important to you and you very much want this medication, you could consider evaluating your insurance and seeing if it is possible to change your coverage in the middle of the year. There are Special Enrollment Periods which allow you to change your coverage in the middle of the year, if you qualify.

This medication is significantly more expensive than you are used to paying, that is for sure. But in the first scenario your plan will be saving you money over the total cost of a year’s worth of medication.

Talk with the pharmacist and see what alternatives you have. Maybe a different medication or maybe paying full price until your deductible is met and then the reduced price would work for you.

If the medication is not covered at all, then maybe a different medication or maybe a different insurance product. The pharmacist cannot help you find the new insurance, but they can help you understand what is happening.

Remember that the person checking you out at the registered is not usually the pharmacist, so ask to speak to the pharmacist.

Good luck with the new medication. I am sorry about the sticker shock at the register.

Janell Sluga is a Geriatric Care Manager helping seniors in our community access services and insurance. To reach her, please email editorial@post-journal.com.