Trying To Explain Drop In Price Of Medication

Question: I just picked up my medication and the cost went way down? Did they charge me the right price? I was afraid to ask.

Answer: I have talked in the past about the four phases of coverage with Medicare Part D; Deductible, Initial Coverage, Coverage Gap and Catastrophic Coverage. The retail cost of your medication moves you through those phases of coverage. The amount you pay is different in every phase. (At the end of this article I have some exciting news about 2024 coverage!)

Usually, we talk about pricing going way up during this time of year because individuals have hit the coverage gap where your cost goes to 25% of the retail cost. If your medication costs $100 retail, you would pay $25. If your medication costs $690 retail, you would pay $172.50.

Most individuals on Medicare do not reach the coverage gap, which is sometimes referred to as the Donut Hole. But when and if you reach that phase, you definitely feel the increased spending. Your medication must total more than $400 per month retail to reach the coverage gap.

You may have been paying that 25% co-pays for the recent months and you now have hit the last phase of coverage called Catastrophic Coverage. Very few individuals reach the Catastrophic phase of coverage. During the catastrophic phase of coverage, you pay $4.15 for generics, $10.35 for brand names or 5% of your medication retail cost (whichever is greater). To reach this phase of coverage in a calendar year, you must have retail medication costs of more than $1000 per month. Statistically less than 5% of individuals with Medicare reach this phase of coverage. It is usually those individuals who are on oral chemotherapy medications or highly specialized medications.

Sometimes we see individuals whose medications cost $28,000 per month, so they go into catastrophic coverage within the first month of the year. But then they still must pay 5% of the cost of the medication for the remainder of the year. For that medication that costs $28000 per month, that is $1250 co-pay for all the months after that first month. That is still a lot to pay all year. Many times, we work with these individuals to find manufacturer assistance programs and grants to help meet these very high co-pays.

In thinking about your question, you may have hit the catastrophic phase of coverage and moved from 25% to a 5% copay structure. This is a bill savings to you. You will stay in this catastrophic phase of coverage for the remainder of the calendar year for all your medications.

The other thing that may have happened is that you enrolled in EPIC, the New York State Pharmacy Assistance Program. This EPIC coverage often has a deductible which is met with your copays as you move through the year. Once your EPIC deductible is met your copays are reduced to never more than $20 for your copay. So, you may want to consider a 90-day supply once you reach your EPIC deductible.

There may be a couple of different reasons that your medication suddenly got cheaper. Look at your receipt and that may help you to determine the reason. Also review your monthly statements you get from your Part D provider that illustrates what your medications cost and how much you paid in the previous month.

Sometimes I hear people say they won’t take their medication because it costs too much, and that is NOT a good decision. You should work with your physician and your pharmacists to see if there are alternative, cheaper medications, or discount programs available.

The really exciting news for me to share with you, is that in 2024 the Catastrophic Phase of coverage becomes $0 (FREE) for all medications once you reach that phase of coverage, if you ever reach that phase of coverage. The Inflation Reduction Act of 2022 includes several provisions that were phased in over time. I remember when I first heard about them, I felt like we couldn’t get there soon enough. But we are fast approaching 2024 and in 2024 the Catastrophic Phase of coverage has a $0 copay for all medications for everyone who reaches that phase for the remainder of the year. That is exciting news for those individuals who reach it.

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


Today's breaking news and more in your inbox

I'm interested in (please check all that apply)
Are you a paying subscriber to the newspaper? *


Starting at $4.62/week.

Subscribe Today