You filled the same prescription at the same pharmacy on the same plan, and it cost more than it did in December. Nothing about you changed. Something about the plan did.
Here is the short list of what it usually is.
The formulary was rewritten
Drug plans rebuild their formularies every year. Medications move between tiers, new restrictions are added, and some drugs leave the list entirely.
Your plan told you this was coming. It arrived in September, in an envelope, as the Annual Notice of Change. Almost nobody reads it, which is understandable — it is long, it is dull, and it is written in a register nobody enjoys. It is also the only warning you get.
You are at a different point in the year
Part D coverage moves through phases across a calendar year, and what you pay for the same medication depends on which phase you are in. January puts everybody back at the beginning.
That is why the January refill of a medication can cost noticeably more than the December one did, with no change to the plan at all. It is not an error and it is not worth telephoning about, though it is worth budgeting for.
The structure of these phases has changed in recent years. For how it works now, and what the current limits are, use Medicare.gov or telephone 1-800-MEDICARE — those are the sources that are correct as of today, which a web page written months ago cannot be.
Your pharmacy’s status changed
Plans have preferred pharmacies where your share is lower. A pharmacy can move in or out of that preferred group between years while remaining in the network.
Same drug, same plan, same shop, different price. If your costs jumped and nothing else explains it, telephone the plan and ask whether your pharmacy is still preferred.
A generic arrived, or went
When a generic version of your medication becomes available, plans often move the brand to a higher tier or off the list. If your prescription still says the brand, you may now be paying the difference by default.
Ask your prescriber whether the generic is appropriate for you. Usually it is. Occasionally it genuinely is not, and that is an exception request rather than a shrug.
You changed plans without meaning to
If your plan left your county, or its contract ended, you may have been moved into a different plan. If you were moved, you were written to. The letter looks like all the other letters.
Check the plan name on your card against the one you remember. It takes ten seconds and it explains a surprising number of January surprises.
What to do about it
Get the number, not the impression. Telephone the plan and ask what you paid, on what tier, and why it differs from last year. Have the drug name and strength ready.
Check the Plan Finder. Medicare.gov will show you what every plan available in your county would cost for your exact list of medications across the whole year. If your plan has become a poor fit, that is where you will see it.
Note the date. Whether you can change anything now depends on the calendar. Annual Enrollment runs 15 October to 7 December. If you are already in an Advantage plan, there is a further window from 1 January to 31 March. Outside those, you need a special enrolment period.
Ask about help paying. Extra Help and the Medicare Savings Programs exist, many people who qualify never apply, and qualifying opens a window to change plans as well. There is a separate guide on this.
The half hour that prevents it
Once a year, in October, sit down with your list of medications and check it against what your plan will look like in January. Use the Plan Finder, or your State Health Insurance Assistance Program, or us — the tool is the same in all three cases.
Thirty minutes in October is the difference between choosing your January and being surprised by it. It is not a sales pitch: the people at 1-800-MEDICARE will do it with you at no cost and with nothing to sell.
If you would rather do it at a table with someone who has seen a thousand of these, telephone us. Bring the bottles.
General information, not advice
This guide describes how Medicare generally works. It is not advice about your situation, and rules, dates and figures change — verify anything that matters to a decision against Medicare.gov,1-800-MEDICARE, or your State Health Insurance Assistance Program, all of which are free.
Rights and rules vary by state; this describes Ohio, Kentucky and Indiana. Clearview Medicare Advisers LLC is not connected with or endorsed by the United States government or the federal Medicare program.
Not sure how this applies to you?
Tell us your birthday and whether you are still working. That is usually enough for us to say which periods apply to you and by when. No charge and no obligation.
