Question: I just went to the pharmacy to pick up my medications and my cost was over $500!! Last year I only paid $42 per month. What happened, I didn’t change my insurance?!?

Answer: During January and the beginning of February we hear this question/comment a lot!

Let me try to explain what might be happening.

When looking back to last January you may not remember what you paid the first time in 2021. Last year your prescription drug coverage may have had a deductible that you forgot about, your plan may have had a lower deductible or had no deductible at all.

This year, 2022, my guess is that your insurance coverage has a deductible. I have come to that conclusion because there are very few products in 2022 with no deductible, so most people will have a deductible with their first medication purchase. It also could be that last year your medications were different and you paid the deductible at lower prices with many different purchases.

Medicare allows up to a $480 deductible, and most plans have that $480 as their deductible amount. Some have a different lower figure, like $200, or $360. The deductible is the amount that you pay full price for your medication until you have spent that much ($200, $360 or $480). Then you move into your initial coverage phase where your insurance company will help pay for the cost of your medications. During the initial coverage period, your co-pays structure may be something like $0, $14, or $47 or $22.64. This last amount ($22.64) could still be the full cost of the medication because the full cost doesn’t get you to the co-pay structure (Tier) that this medication belongs in.

Your cost of over $500 could also be because your medication isn’t covered by the plan you are in. It is my hope that you looked at the medications you take and you made sure that the plan you chose or decided to stay in from last year were still covered. Some people don’t evaluate that decision for the new year (2022). They choose a product based on a recommendation of a friend, or an advertisement they see. We make assumptions that ALL medications are covered the same by ALL insurance. This is NOT the case. Each insurance product makes its own rules for coverage of all the medications available. Just because your insurance last year had your medication cost $42 per month, doesn’t mean that all plans have that same cost structure.

If you kept the same insurance product that you had last year you may be running into this same situation because insurance products change year to year. The plans change the deductible, change the Tier that medications are assigned to and the contracts with the pharmacies. All of these factors influence the amount you pay for your medications.

The first prescription fills of the year can be frustrating. Almost every person that comes to the counter has some question, or needs clarification on the cost. We may assume the pharmacy made a mistake. As a result, the Pharmacist explains, that it isn’t their fault, it is the plan you chose/have. Insurance Companies decide on the coverage rules and rates. The pharmacist fills the medications you take your insurance coverage guidelines. Then the pharmacist gets to hand it to you and explain why it costs over $500.

January through February is a tough time of year to be a Pharmacist. I would like to designate this month as “Hug Your Pharmacist” month. My tough time of year (October, November & December) has just ended. For the Pharmacist (and you) the frustration and questions has just started.

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 2023. 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 716-720-9797 or email SLM@lutheran-jamestown.org.