Rx Nopays

June 22, 2007 by bob.

Q. I currently have a plan with an Rx copay. For quite some time I have taken (name withheld) medication and paid my $40 copay. The last time I used my card the pharmacist told me I had to pay over $80 for my medication. My plan has not changed. Why is this pharmacist over-charging me?

A. You are not being over-charged by your pharmacist. Rather, your plan is doing exactly what it should.

If you read your policy (something everyone should do at least once) you will see a 3 tier copay plan. Tier 1 is for generics (and usually the generic copay is much higher than you would actually pay for the med without your card). Tier 2 is for older, more established brand name drugs. Tier 3 has the highest copay and is used for the newer drugs that are regularly advertised in print and on TV.

Your plan Rx manager has noticed that you are taking a tier 3 med that has a lower priced, tier 2 equivalent. The allowance for meds reverts to a lower tier when an equivalent med becomes available.

The same would happen if there were a generic equivalent to a tier 2 or tier 3 med.

You would then be allowed the copay on the lesser priced med and you pay the difference.

If you were to change to a plan without copays you would most likely realize a significant total savings in premium + out of pocket.

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