A formulary is a list of drugs (Medication) divided into five “Tiers” published insurance providers that lists what drugs their plan covers by Tier. The problem is, each insurance provider has its own criteria of what drugs are in which category. The formularies are reviewed annually and adjusted by the insurance providers
Adjustments include such actions as moving a drug from one tier to another, or excluding (dropping) a drug from its coverage. The results of this annual adjustment is a bait-and-switch tactic that penalized the patient. Here is an example
A patient was enrolled in Medicare Part D for 2020. The patient pays $204 a year, deducted from its Social Security payment. During late 2020, the Medicare contractor for Part D sends a communication (booklet) with the adjusted formulary. No pricing information is provided.
In 2021, the first refills, shows a drug has moved from Tier 2 (no copay or deductible) to Tier 3. The drug is Nifedipine ER 30mg tablet, a generic for Procardia XL 30mg tablets. The patient has been using Nifedipine for several years.
In 2020, a 90-day supply was $12.50 as a Tier 2 drug. In 2021, the insurance provider moved the drug to Tier 3. The price changed from $12.50 to $139.88, an eleven-fold increase. That’s not all. There is a $445.00 deductible in Tier 3. So the patient will pay a total of $204 + $445 + $114.52 = $763.52 in 2021 versus $204 + $50 = $254 for this drug in 2020. This is an increase of 300% simply by moving a drug from Tier 2 to Tier 3.
When contacting both the insurer, its pharmacy and Medicare, when the price increase was first noted (Feb 2) when the credit card was billed), this is the process to challenge the price increase:
Call the pharmacy – they don’t control the price, advise to contact the insurer
Filed a grievance with the insurer
Called Medicare – cannot assist until insurer’s grievance settled
Received formal closure that price will not change and deductible still applies
Called insurer – advice file another grievance
Called Medicare – no way out until next enrollment period
This process takes 60 – 90 days or more – on the patient to resolve. Bottom line, no remedy for the patient. Only recourse, discontinue using Medicare contractor, us Single Care or GoodRx and buy at your local pharmacy and exit Medicare Part D at next enrollment period.
This is price gouging against Medicare patients. The shame is that Medicare is not looking out for bait and switch by their prescription providers. In this case, the insurance and big pharma lobbyist are going unchecked. The senior citizen expects more of CMS.
Nifedipine 30mg ER tablets, 90 count, are available on the Internet from GeniusRX via Single Care for $14.61. (Source)
What is needed is for CMS to pay attention to its contractor’s formularies, and develop a standard formulary for all its contractors supporting Part D, and watch the bait-on-switch between Tiers, and no matter how the contractor justifies its movement and prices, check the Internet for price checks.