If a medication you have taken for years suddenly costs more in January, nothing about your prescription changed. Your plan's formulary did.
What a formulary is
A formulary is the list of medications your plan covers and what tier each one sits on. Tier decides your copay. Most plans rebuild that list once a year, effective January 1, based on rebate agreements they negotiated with manufacturers months earlier.
A drug can move to a higher tier, get a new prior authorization requirement, get a quantity limit, or come off the list entirely. None of that requires anyone to tell you in advance beyond a notice buried in your annual plan documents.
The four things that usually happened
- Your medication moved up a tier, so the same drug now has a higher copay.
- Your plan added a prior authorization requirement, so it needs your doctor to justify it before covering anything.
- Your plan added step therapy, meaning it wants you to try a cheaper drug first even though you are already stable on this one.
- Your deductible reset. If your plan has a pharmacy deductible, January is when you start paying full price again until you meet it.
That last one catches people every year. It is not that the drug got more expensive. It is that you are paying the full negotiated price until the deductible is satisfied, and then the copay you are used to comes back.
What we do about it
When a price jumps at our counter, we do not just tell you the number. A pharmacist checks whether a manufacturer copay card applies, whether a patient assistance foundation covers your situation, whether a different quantity or day supply changes the math, and whether a therapeutically equivalent drug sits on a lower tier.
If a lower-tier alternative exists, we will tell you what it is so you can raise it with your prescriber. We will not switch anything without your doctor's decision, but you should not have to discover the option yourself.
What to do right now
- Call us before you decide to skip a fill. Most of these are solvable and the solution takes one phone call from our side.
- If you are on Medicare, January is also when you can see whether your Part D plan is still the right one. We can compare what your specific medication list would cost under the plans available to you.
- If your deductible reset, ask us whether a 90-day supply changes your total out-of-pocket for the year.