{"id":31108,"date":"2023-10-31T19:45:14","date_gmt":"2023-10-31T19:45:14","guid":{"rendered":"https:\/\/isafespend.com\/personal-finance\/retirement\/if-a-drug-copay-is-outrageous-maybe-your-part-d-plan-doesnt-cover-it\/"},"modified":"2023-10-31T19:45:16","modified_gmt":"2023-10-31T19:45:16","slug":"if-a-drug-copay-is-outrageous-maybe-your-part-d-plan-doesnt-cover-it","status":"publish","type":"post","link":"https:\/\/isafespend.com\/?p=31108","title":{"rendered":"If A Drug Copay Is Outrageous, Maybe Your Part D Plan Doesn\u2019t Cover It"},"content":{"rendered":"
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We are only two weeks into the Open Enrollment Period, and I have encountered four clients who are very dissatisfied. They complain that the copayment for a new drug is \u201cinsane\u201d or \u201cridiculous.\u201d In other words, they are paying way too much. These clients have two things in common. One, they are all unhappy and, two, the drug is not covered by their Part D plan.<\/p>\n

They have questions about this situation so here are some answers.<\/p>\n

Why is a drug not covered? <\/em><\/h2>\n

There are two reasons. This can happen whether you have a stand-alone Part D drug plan or a Medicare Advantage plan that includes drug coverage.<\/p>\n

1. The drug is not on the <\/strong>plan\u2019s formulary<\/strong> (list of covered medications).<\/strong><\/p>\n

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Medicare identifies protected classes of drugs, such as anticonvulsants and antipsychotic, that every Part D and Medicare Advantage plan with drug coverage must list on its formulary. Beyond those classes, a plan must cover at least two. Two of these clients were taking insulin that was not on the plan\u2019s formulary.<\/p>\n

2. <\/strong>The pharmacy is out-of-network<\/strong>.<\/strong><\/p>\n

Technically, the medication is covered but the pharmacy isn\u2019t because it\u2019s not in the plan\u2019s network and you pay full price.<\/p>\n

What are the repercussions if you take a noncovered drug?<\/em><\/h2>\n

The first, and probably most significant, is that you pay full retail cost. For example, a common drug for blood clots has a retail price in one plan of $545. A specialty medication for treatment of arthritis is over $6,000.<\/p>\n

A second repercussion is more in the weeds. What you pay for this noncovered drug does not move you through the Part D payment stages. If you pay hundreds of dollars for a covered drug, you could land in Catastrophic Coverage and not pay anything for medications the remainder of the year. But that won\u2019t happen if a drug is not covered. You\u2019ll just keep pulling out your credit card.<\/p>\n

Why did this happen?<\/em><\/h2>\n

The physicians sent an order to the clients\u2019 pharmacy of choice that filled the prescription and delivered it to the question this because rising drug costs are just a sign of the times. It\u2019s possible that the pharmacy staff was just too busy to check or communicate with these individuals, which may be another sign of the times.<\/p>\n

What can you do to prevent this? <\/em><\/h2>\n