Timothy Masters—Getty Images/iStockphoto
By Katherine Hobson
November 2, 2016

Prescription drug costs are riling up everyone these days—the EpiPen brouhaha is only one example of a trend that’s also affecting routine medications. And insurers hit by those price increases may pass costs along to consumers with tiered formularies requiring them to pay a greater share of the bill.

Here’s what you need to know.

Do Your Homework During Open Enrollment Season…

When you’re shopping for a plan during open enrollment season, take note of any drugs you take regularly and see if they’re on the plan’s formulary. If they are, see where they fall in the plan’s tier system; the higher the tier, the more you’ll owe as a co-pay or co-insurance.

…But Watch Out For Changes

“A lot of people with chronic diseases look for a plan where their drugs are covered,” says Sandy Ahn, an associate research professor at Georgetown University’s Center on Health Insurance Reforms. “But health plans can make midyear formulary changes.” Your preferred drug could be bumped up to a higher tier, or made subject to prior authorization, or taken off the formulary altogether and replaced with a similar drug.

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If you’re on Medicare, the changes won’t kick in for you until the following coverage year. But if you’re on private insurance or on the marketplaces, there’s no such protection. (Unless you’re in a state that caps out-of-pocket costs for high-cost drugs.) And you aren’t permitted to switch plans mid-year simply because of the change.

Ask for an Exception

If your drug is removed from the formulary, you have the right to ask for an exception. (If it’s simply moved to a higher tier, with higher cost-sharing, you’re out of luck.) Your pharmacy benefit manager should have an exception form, says Pat Jolley, clinical director of research and reporting at the nonprofit Patient Advocate Foundation. Get your doctor involved and gather as much proof as you can, such as documentation that you have a medical reason for wanting the specific medication, she says.

Be Prepared to Jump Through Hoops

Some insurers use “step therapy,” where you are required to try a cheaper option to see if it works before being covered for the more expensive option. The trouble comes if you have a specific medical reason for being prescribed the pricier drug, yet still have to try the cheaper treatment. Again, you need to get your physician involved. Jolley says you need to gather as much evidence as possible when you appeal, including any specialists’ reports, lab reports or progress notes.

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If you’ve already tried the less expensive drug, explain why it didn’t work for you. The bad news is that if your plan changes, you may have to go through the process all over again, she says. (Some states have laws making it easier to get an exception.)

Look for Help

Even if your drug is covered by insurance, your out-of-pocket costs from a co-pay or co-insurance can add up. Manufacturers’ patient assistance programs can sometimes help, says Jolley. Also, be aware that your plan likely has preferred pharmacies where your costs will be lower. And mail-order pharmacies are often cheaper than going to the drugstore. She also advises checking GoodRx, which shows the price of your drug at local pharmacies. With discounts and coupons, sometimes the price is lower than a co-pay.

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