New Year, new prescription coverage: What do I need to know?

This time of year many of us are setting new goals, often with the hope of creating healthier habits – like losing weight, following doctor’s orders, or taking our medications daily! If you have a new prescription insurance plan, you may be in for a surprise at the pharmacy counter. The copay on your medication may be more than you were anticipating, or worse yet, it may not be covered at all. Prescription drug plans, a.k.a. prescription benefit managers (PBMs), make adjustments to the list of drugs they cover (their formulary) each year, and the copay can also change from a lower tier (cheaper) to a higher tier (more expensive).

Some reasons for these changes include:

  • A previously brand name only drug is now available as a generic
  • Manufacturers negotiate special contracts with insurers to obtain preferred status for their drug (and vice versa another med has become non-preferred)
  • Increasing copays to offset rising costs for health plans
  • New clinical information supports a medication’s preferential use OR no longer recommends its use

For example, a patient stops by her local retail pharmacy to pick up a refill of her Invokana (canagliflozin) for type two diabetes. When the technician rings up the prescription she is surprised to hear that its cost is $75, when last month it was only $30. There are 3 people in line behind her so she feels pressure to fork over the cash, rather than ask questions, because she doesn’t want to discuss her personal medical information in public. Sound familiar?

It turns out that her medication is no longer a preferred brand name drug in its class. However, if she had been able to talk with a knowledgeable pharmacist she could have discovered that Jardiance (empagliflozin) is in the same class and is now the preferred drug on her insurance plan. A quick phone call to her prescriber by the pharmacist can get the medication changed and save her $45 a month.

A personal pharmacist can be an invaluable help when navigating the complicated world of prescription insurance and medication management. If you think you might need some help, check us out at

Kristen Engelen, PharmD
Kristen Engelen, PharmD, is the chief pharmacy officer of RxLive and a certified consultant pharmacist; she has over a decade of experience in retail pharmacy settings. Kristen became an RxLive co-founder because of her passion for geriatric pharmacy, with a focus on the intersection of pharmacy and aging.