“Why is my copay so high?”
This is another common question that gets asked by customers. Depending on what time of the year it is can explain why copays are more expensive than they are usually.
The majority of our customers have commercial plans (plans their employer or themselves pay for) or government funded plans(Medicare Part D or Medicaid).
The following are things I consider to be factors that contribute to higher copays.
Different plans will have different contracts signed with different pharmacies. The preferred pharmacies will give customers lesser copays while non-preferred pharmacies will have higher copays. Please make sure you are aware of which pharmacy is preferred with your plan. You can do so by calling your insurance plan.
In some cases plans will prefer mail-order pharmacies. In these instances, the customer will have a regular copay for 2 fills, but then will have to convert to mail-order for their subsequent refills. Some customers are not aware of this. When they show up to pick up their prescriptions, they are presented with a much higher copay, as the plan is penalizing them for not converting to mail-order.
The reason I mention why time of year matters is that for most, these plans have deductibles that have to be met. In January, when deductibles are reset, a lot of people forget that they even have a deductible. Others may have plan changes and now they have to pay a deductible. Once these deductibles are met, they are able to pay the copays set by their plan.
Medications are put into different tiers. They range from tier 1 to tier 6 for most plans. Drugs listed in tier 1 will have the lowest cost while drugs in each tier after will be more expensive. Most generic drugs will end up being in tier 1 while higher costing generics would be in tier 2. Most brand name drugs will start in tier 2 and move down from there. The higher costing brand name drugs end up in tier 4. This is where you sometimes see some crazy copays that are several hundreds of dollars!
There is an unfortunate trend of increasing drug prices. Back in 2001, a vial of insulin could be purchased for less than $50. Now that same vial of insulin could be purchased for around $200. A more extreme case of this involves a cream that I was looking to order recently. In the past this cream was around $360. When i looked to order it the other day, this same cream had a staggering price of just under $6000! Drugs with these types of prices end up being in the higher tiers, which result in higher copays for customers. Unfortunately doctors do not know about these prices most of the time and prescribe what they believe are best for their patients. This usually results in time spent to call the doctor and have him/her change the medication.
Medicare Part D Coverage Gap:
Patients with Medicare part D have what is called the coverage gap, AKA “The Donut Hole.” For 2019 that period of coverage starts when your drug spending reaches $3820 on covered drugs and ends when you reach $5100 in out-of-pocket spending. During this time, copays for brand medications are no more than 25% of the drug price. As mentioned before, with increased drug pricing, this can still be rather expensive for some customers. The only benefit is that it can help them get out of the coverage gap sooner and into catastrophic coverage where only a small payment or copay is needed. For generic drugs, expect to pay %37 of the drug price as a copayment.
As you can see, many factors can lead to higher copays than expected. If and when you see a copay that you don’t agree with, please do not hesitate to question the pharmacy staff or call your insurance. Where I work, once a prescription is paid for and leaves the pharmacy, it cannot be returned. The same may apply to you and your pharmacy.
In an upcoming post, I will address ways to possibly lower your copay. Stay tuned.