Licensed Independent Agent, Texas Insurance Alliance, Little Elm, TX
Prescriptions are covered under a Part D plan (prescription drug plan) or Part C plan (medicare advantage plan). Every plan has a unique formulary that determines what tier each medication is categorized as or if it is even covered by the plan. Typically brand drugs are a tier 3 or higher and have a higher copay when filled at your in-network pharmacy. Some brand drugs have a generic alternative which puts them at a tier 1 or tier 2 which usually has a lower copay. Some plans provide for $0 copay for generics or at least a discount on your copays if you use a mail order pharmacy and may allow you to receive up to a 90 day supply of your medications. Be sure to read about any applicable prescription deductibles and coverage gaps/catastrophic gaps (commonly called 'the donut hole') that may apply to these plans as that may cause the copays to change.
Cymbalta will have different costs with each Part D RX plan or the Rx plans built inherently into Medicare Advantage Plans (Part C plans). Each plan has a formulary which tiers the drugs and then ties each tier to a copay. You will not find Cymbalta in a lower copay tier with most carriers as they will all have it listed as a tier 3 or tier 4 medication. There are some plans that have lower copays associated with tier 3 however. Most companies charge a $45 to $50 copay for a one month supply of a tier 3 drug. There are some plans that have a $18 to $25 copay for tier three which could save you some money.
The last thing to keep in mind is regardless of the copay amount, a drug like Cymbalta is going to push you into the Part D coverage gap "donut hole" much faster than a lower cost generic would do.
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The last thing to keep in mind is regardless of the copay amount, a drug like Cymbalta is going to push you into the Part D coverage gap "donut hole" much faster than a lower cost generic would do.