I Thought My Co-pay Would Be $47. Why Did I Have To Pay $453.45?
Q: I’m enrolled in a Part D drug plan. I thought I would get my brand name drug Eliquis, for a $47 copay, but I was charged $485.45. Why was that?
A: There could be several reasons that can cause sticker shock at the pharmacy. Here are some tips for checking the charges and understanding the costs associated with your new drug plan:
- Locate the booklet of information about your drug plan for 2020. Your drug plan is required to send you “Evidence of Coverage” for 2020, a booklet that outlines your plan’s coverage for your prescription drugs, and what you pay in general. If you don’t have that information from your drug plan, or if you don’t see answers to your specific questions, you can call the customer service representative of your drug plan directly, or you may find information about your drug plan online by searching drug plans at www.Medicare.gov.
- Check to see if your drug plan has a deductible, and how much the deductible should be. The number of drug plans that are charging a deductible increased in 2020, and a larger percentage of the plans is charging the full standard deductible of $435 in 2020. A deductible is the amount you pay before your coverage kicks in. Deductibles can vary in how they are applied. You may get coverage for generics from day one, but you are probably going to be required to satisfy a deductible for your Eliquis. Of particular note, enrollees in the SilverScript Choice plan paid no deductible in many regions of the U.S. last year, but they will pay as much as $435 in 2020. A similar situation affects enrollees of the Humana Enhanced plan, who paid no deductible in 2019. For those who chose to remain in the plan — which is now called Humana Premier Rx, they will pay a $435 deductible.
- Check to see if Eliquis is covered by your drug plan and the cost sharing for the tier in which it is listed. Many drug plans have five tiers covering preferred generics, generics, preferred brands, non-preferred brands and specialty drugs. Check to see where Eliquis fits in on these tiers (probably preferred or non-preferred brand). It’s not uncommon for insurers to move a drug from preferred brand to non-preferred brand status, causing you to pay more out-of-pocket. For example, your plan in 2019 may have charged a co-pay of $47 for preferred brands, but if Eliquis was moved into a non-preferred tier in 2020 you might have to pay 50% co-insurance or about $235.00.
- Find out which drug store has the lowest cost-sharing before you fill. Your cost sharing can be dramatically higher depending on where and how you fill your prescription (retail versus mail order). Make sure you are using a preferred vs. standard network pharmacy and compare the prices of retail pharmacies with getting a 90-day supply from your drug plan’s mail order pharmacy. For example, if you are enrolled in the Wellcare Wellness Rx plan and get your Eliquis from a standard in-network pharmacy, your copay for Eliquis after the $435 deductible would be $47 during the initial coverage phase, and $117.38 in the Part D coverage gap. However, if you get your Eliquis from a preferred in-network pharmacy the co-pay is $40.00 during the initial coverage phase and $113.36 in the coverage gap. Depending on where you live, and your drug plan’s mail order pharmacy, sometimes you may save a little more using mail order.
- Get free one-on-one counseling. If all this makes you want to run away screaming, but you still have questions, just call your State Health Insurance Program (SHIP). You can get free one-on-one Medicare benefits counseling that can help you check your drug plan and figure out your charges. Many of these programs operate through local area agencies on aging. You can find local contact information at this website: https://www.shiptacenter.org.