Janell Sluga Medicare & Individual Health Insurance Account Executive View Bio

 Question: I just went to the pharmacy to pick up my medications and my cost was over $550!! Last year I only paid $42 per month. What happened, I didn’t change my insurance?

Answer:

During January and the beginning of February I hear this almost daily! I can probably tell you what is happening, because it’s one of two situations. The first is that your plan has a deductible (up to $590) and you haven’t met that yet. The second is that your medication is no longer covered by your plan in 2025. I’ll explain both situations here.

First, let’s consider the deductible situation. When looking back to last January 2024, you may not remember what you paid the first time last year. Your prescription drug coverage may have had a deductible that you forgot about, your plan may have had a lower deductible, or it had no deductible at all.

Let me briefly explain your deductible. For your prescriptions, the deductible is like minimum amount you must spend before coverage “kicks in.” Before “meeting your deductible” (aka spending that minimum amount), you must pay full-price for your medications. Then once you meet that deductible (aka spend enough money on full-price medications), you move into your initial coverage phase. Then your insurance company will help pay for the cost of your medications, but you likely still pay a copay. The initial coverage phase usually structures their co-pays as tiers, where you may pay as low as $0 for certain drugs called Tier 1, then say $14 for Tier 2 drugs, and so on, usually up to Tier 5 or 6 at about $20-$30.

Most plans come with a deductible this year, so you probably have one. Also, the maximum allowable deductible this year is $590, and that is the most common deductible we’re seeing across plans this year. Medicare allows up to a $590 deductible, and in fact that is the most common deductible across plans this year. Some plans do have a deductible of just $450 or even $200 though.

The second reason your cost is over $550 could 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 each year. 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 your plan has that same cost structure in the new year, or that it even covers your medications at all.

If you kept the same insurance product that you had last year, you may be running into this situation because insurance products change year-to-year. The plans change the deductible, the list of covered medications, the Tier that medications are assigned to, and their contracts with pharmacies. Note even if your plan did not change at all, your medications could have been different, and you paid the deductible at lower prices over several different purchases. 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 your plan, because your insurance companies decide on the coverage rules and rates. The pharmacist will charge you for your medications according to your specific plan’s rates.

January through February is a tough time of year to be a Pharmacist – I would like to designate these months as “Hug Your Pharmacist” months. My tough time of year (October, November & December) has just ended. For the Pharmacist, and you, the frustration and questions have 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 2026. The more feedback they get, the better they will understand how we like their products. You also may have an opportunity to change your insurance now or later in the year even if you didn’t evaluate it during October-December. Give your insurance agent a call or use the Medicare.gov website to evaluate your options.

If you have questions or need assistance navigating your options, don’t hesitate to reach out to the Lawley Medicare Solutions Team. You can contact Medicare Service Team Lead Gabrielle Connor at 716.849.8223, or submit an inquiry through our contact form below. We’re here to help you find the right coverage for your needs!

At Lawley Medicare Solutions, our Medicare and Individual Health Consultants are dedicated to helping you make the most informed decisions about your healthcare needs. We offer personalized service and expert advice tailored to your unique situation. Contact us today by phone or email to schedule a consultation and ensure you’re getting the best coverage for your needs.

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Our licensed Medicare & Individual Health Insurance team can help clients understand the details of Medicare insurance plans, assist with choosing the right benefits and coverage, and provide guidance when life events that affect health coverage occur.

For questions, concerns, or to reach Lawley Medicare Solutions, call 716.849.8223.