What to Do When a Drug Gets More Expensive

Do not start with panic

A drug-cost jump is unsettling. The pharmacy counter is not the place to make a decision. You do not have to fix it that day. You do have to find out what changed.

There are usually about a dozen reasonable explanations. Most of them are sortable in a single phone call.

Possible reasons the cost changed

Any of these could be the cause, alone or in combination:

• Deductible phase. Many Part D plans have an annual deductible that resets January 1. The first fill of the year often costs more than later fills.
• Tier change. Your drug may have moved from a lower tier to a higher one.
• Formulary change. Your drug may have been removed, or covered differently.
• Brand/generic status change. A drug that was generic may have a name-brand version your plan is now defaulting to, or vice versa.
• Preferred vs. standard pharmacy. If your pharmacy changed status, your cost-share may have moved.
• Prior authorization or step therapy. A new requirement may now apply.
• Quantity limits. A 90-day fill may have become a 30-day fill.
• Plan year change. A new plan year starts January 1; costs reset.
• Pharmacy billing issue. Sometimes the prescription is run on the wrong card or the wrong plan.
• Extra Help / LIS change. Eligibility for low-income subsidy can shift.
• Medication itself changed. A new dose, a new strength, or a substituted product can affect price.

Most of these are knowable with a five-minute call to the plan or the pharmacy.

What to write down

Before you call anyone, write down: drug name, dosage and strength, frequency, pharmacy, plan name (and member ID), date the cost changed, old price, new price, and whether you received a notice (and what it said).

A clear write-up makes every conversation shorter.

Who to verify with

Different people answer different parts:

• The plan (member services). What changed about the drug's coverage? Tier? Formulary? Restrictions?
• The pharmacy. Did the way the prescription was run change? Was it a preferred-pharmacy issue?
• Medicare.gov Plan Finder. Compare drug coverage across plans with your exact medication list.
• Your state SHIP. Free, unbiased counselors who can help work through complex cases.
• The prescribing doctor. Is there a therapeutic alternative that fits your plan better? Sometimes a small change in prescription can change the cost a lot.
• Extra Help / LIS source if applicable. SSA.gov for low-income subsidy questions.

How this applies to you

If the change is small and likely a deductible issue: Often nothing to do. Wait for the deductible to clear, then check again.

If a drug is no longer covered: Talk to your doctor first about alternatives. If alternatives won't work, ask about a formulary exception or appeal.

If your plan now requires prior authorization or step therapy: Your doctor's office can help with the paperwork. This is usually fixable but takes time.

If you take several medications and several costs moved: It may be time for a full Part D review during the next Open Enrollment.

When to revisit coverage

A single drug-cost change is rarely a reason to switch plans mid-year. But if a recurring medication no longer fits your plan well, that change is worth carrying into Open Enrollment for a full review.

The four questions

How does that apply to me? Is this a once-a-year deductible thing or a permanent shift?

What am I assuming? Am I assuming the plan changed, when it might be the pharmacy?

What should I verify? With the plan, the pharmacy, the doctor.

What might be harder to change later? If you wait past Open Enrollment, options narrow.

How Fern helps

Fern can help sort the likely categories and turn them into call questions. You do not have to figure out the right person to call before you call them. If you have a notice, plan letter, drug-cost change, or something someone told you, Fern can help you turn it into clearer questions and next steps.