Why drug prices fluctuate | News, Sports, Jobs


Question: I went to pick up my medication and it cost me $154.26, last time it was $42. What happened and why is it so expensive?

Answer: Each insurance company handles co-payments differently and their policies may change from year to year. So even if you haven’t changed your prescription drug coverage for 2022, your coverage may actually be quite different.

Some universal rules apply to coverage. Each company defines its Formulary, the list of drugs covered by the plan, and will contribute to pay. No plan covers every drug on the market, so each formulary is a little different. The formulary can cover different drugs with different copayment amounts.

Medicare prescription drug coverage excludes drug categories such as; Barbiturates, benzodiazepines, medications used for anorexia, weight loss/gain, fertility, hair growth, cold symptoms, most vitamins and over-the-counter medications.

Insurance companies decide which drugs to include in their formulary, they also decide how they will cover those drugs. It’s the “hierarchy” medication. The medications covered by your insurance company are grouped into tiers, and your co-pay is determined by the tier your medications are at. Insurance plans usually have five or six levels. Your drug plan places each drug it covers into a tier, and different rules apply to different tiers.

Briefly, the two types of drugs that make up the tiers are brand name drugs and generic drugs.

A brand name drug is a drug sold by a pharmaceutical company under a protected brand name. Brand-name drugs can only be produced and sold by the company that holds the patent for the drug. Brand name medications are available by prescription and over the counter (for example, Eliquis or Zyrtec). An example is Synthroid; Synthroid (prescribed as a brand name), costs most people with Part D plans between $30 and $45 per month for the drug. Synthroid is available as a generic named Levothyroxine. If you get generic Levothyroxine, it can cost anywhere from $0 to $12 per month. This is an important difference.

A generic drug is available when a brand name drug’s patent expires. This means that other companies can produce a generic version of this brand name drug. The generic version of the drug must use the same active ingredients as the brand name drug and must meet the same quality and safety standards as the brand name drug. Additives and colorants may be different, so it does not look the same and is not exactly the same as the brand name.

During the coverage gap (Donut Hole), drugs are 25% of the retail price. Using Synthroid and Levothyroxine, this 25% price is very different. Synthroid costs around $48 for a 30 day supply, so 25% becomes $12 per month. Levothyroxine costs about $7 for a 30 day supply, so 25% becomes $1.75 per month. In this example, the difference is small, but there may be significant differences for the consumer depending on the drug. The example of Advair ($425 per month) at 25% becomes $106. Generic Fluticasone/Salmeterol ($75) 25% becomes $18.75.

I use Synthroid and Advair as examples because your cost sharing is different in the initial coverage phase due to drug prioritization. In the coverage gap, the cost difference is based on the retail price of the drug. Therefore, you need to review your plan and how it covers your medications each year. You should not assume that your share will be the same from year to year or within the year.

I often hear from people after they return from the pharmacy. They are shocked and angry that their drugs cost different amounts than last year or last time. Your company sent you information about how your costs were going to change, called Annual Notice of Change around October 1 of last year. Look at this material now and see if what is happening to you is described in the material sent to you. If you think this is NOT reflected in the material sent to you, call the insurance company. You can ask questions, you can request exceptions, you can talk to your doctor about a different drug.

The more you know, the more you can fight for your rights!

Senior Life Matters is a community program sponsored by Lutheran Jamestown. For questions or concerns or to reach Janell Sluga, GCMC, call 716-720-9797 or email [email protected]



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