Have you ever picked up a prescription you’ve been taking for months and suddenly wondered:
“Why is my copay different this time?”
You’re definitely not the only one. It’s a question we hear regularly at Cornwell Pharmacy.
When you’ve paid the same amount month after month, an unexpected change can be frustrating and confusing. But there are actually several reasons the price you pay for a prescription can change from one fill to the next.
And one important thing to understand is this: the pharmacy doesn’t simply choose your insurance copay.
When we process a prescription through your insurance, your plan sends back the amount you’re responsible for paying. Here’s why that amount might change.
Your Insurance Plan or Benefits Changed
A new insurance plan is one of the most obvious reasons for a different copay.
But you don’t necessarily have to switch insurance companies for something to change. Your plan’s benefits, formulary, deductible, or preferred medications can change from one plan year to the next.
Sometimes when we point out that we’re billing a different plan than we used for the previous fill, the mystery is solved pretty quickly.
You’re Working Toward a Deductible
Some prescription insurance plans have a deductible that must be met before the plan begins paying a larger portion of your medication costs.
That can mean paying more for prescriptions early in your plan year and less after you’ve met your deductible.
Many deductibles reset at the beginning of a new plan year, which is why patients commonly notice prescription prices changing around the time their benefits renew.
Your Medication’s Formulary or Tier Changed
Insurance companies maintain lists of medications they cover, commonly called formularies.
Medications may also be placed into different tiers that determine how much the insurance pays and how much the patient pays.
Your medication could move from a preferred tier to a non-preferred tier, or your plan could change which products it prefers. When that happens, your copay can change even though your prescription hasn’t changed at all.
Something About the Prescription Changed
Sometimes a small change in the prescription itself can result in a different price.
A change in:
- Strength
- Quantity
- Days’ supply
- Dosage or directions
can affect how your insurance processes the claim.
For example, your insurance may handle a 30-day supply differently from a 90-day supply. Even though you’re taking the same medication, the amount you pay may not simply be three times, or one-third, of the other price.
A Coupon or Savings Program Changed
Sometimes the amount you’ve been paying isn’t solely your insurance copay.
A manufacturer savings card, coupon, or other assistance program may have been helping reduce your out-of-pocket cost. These programs can have expiration dates, annual limits, eligibility requirements, or other restrictions.
If a savings program stops applying, the price at the pharmacy counter may suddenly increase even though your insurance coverage hasn’t necessarily changed.
Your Insurance Returned a Different Price
This is probably one of the most misunderstood parts of prescription pricing.
When Cornwell Pharmacy submits your prescription claim, we don’t simply tell your insurance company what we’d like you to pay.
Your insurance plan processes the claim according to its benefit rules and contracted pricing and sends us the amount you’re responsible for.
That amount can be affected by your deductible, formulary status, medication cost, plan design, and other factors.
In other words:
The pharmacy doesn’t simply choose your insurance copay.
Sometimes the amount your insurance returns today can be different from what it returned the last time you filled the prescription.
There Could Be an Issue with Your Coverage
Occasionally, a surprising prescription price may be caused by an eligibility or coverage issue.
Your insurance may show that coverage is inactive, information may need to be updated, or there may be another issue with your plan.
In those situations, we may need you to contact your insurance company directly because they’re the ones who can correct the underlying coverage issue.
If Something Doesn’t Look Right, Ask Us
There are a lot of moving pieces behind the scenes when an insurance company processes a prescription claim, and we’ve only scratched the surface here.
That’s why we never want you to be afraid to ask:
“Why is my prescription more expensive this time?”
At Cornwell Pharmacy, we can review how your claim processed and often help identify what’s different. If there’s something we can correct on our end, we want to fix it. If the change came from your insurance company, we can at least help you better understand what happened and what questions you may need to ask your plan.
Prescription insurance can be complicated.
You don’t have to figure it out completely on your own. If your copay doesn’t look right, ask us. We’re happy to take a closer look.
