Keeping the same plan doesn't guarantee the same copay. Every plan's drug list — its formulary — gets rebuilt each year, and a medication can move to a different tier even when nothing else about your plan changes. That's true whether the plan changed its name or not.
What a formulary tier actually is
Each plan sorts covered drugs into tiers, generally from lowest-cost generics up through higher-cost brand-name and specialty drugs. The tier a drug sits in — not just whether it's covered — is what determines your copay.
A drug can stay covered from one year to the next and still cost you differently, simply because it moved from one tier to another.
Why tiers move at all
Formularies are rebuilt annually, and drug pricing, manufacturer agreements, and plan contracts all shift over the course of a year. A generic alternative becoming available, a pricing agreement changing, or a plan simply reorganizing its tier structure can all move a drug from one tier to the next.
None of this requires you to have done anything differently. The plan itself can change shape around you.
Why this is easy to miss
Nothing about your enrollment or your plan's name changes when a tier shifts, so there's no obvious signal telling you to look. Most people find out at the pharmacy counter, when a refill that used to be a flat copay suddenly isn't.
That's avoidable — the coming year's formulary is published before January, which means it can be checked ahead of time.
Why the same drug can cost differently at different pharmacies
Tier isn't the only variable. Many plans also set different costs depending on which pharmacy fills the prescription — a preferred pharmacy in the plan's network generally costs less than a standard in-network pharmacy, even for the same drug at the same tier.
That's a separate check from the tier itself, and it's worth doing at the same time, since a pharmacy that was preferred this year isn't guaranteed to stay preferred next year either.
What to do if a drug moves to a higher tier
If a checked drug does move to a higher tier, there are usually a few paths worth asking about: whether a lower-tier alternative exists for the same condition, whether the plan's coverage stage changes the math later in the year, or whether a different plan's formulary treats that same drug more favorably.
None of those are guesses to make on your own — they're specific questions a review is built to answer.
What's worth checking
A useful drug-list check covers:
- Every prescription you currently take, by name and dosage
- The tier each one sits in for the coming plan year
- Whether your regular pharmacy is still a preferred pharmacy under the plan
- Whether any drug now requires prior authorization or step therapy that it didn't before
How this fits into a plan review
A plan review checks your full medication list against next year's formulary in one pass, the same way it checks your doctors against next year's network. You get a specific answer for each medication, not a general sense of whether the plan is "good" for drug coverage.
If a call is easier than digging through a formulary PDF, that's exactly what a review is for — (305) 859-1704 gets you a person, not a portal.
The bottom line
The plan can stay exactly the same and the copay can still move. Checking the drug list directly, rather than assuming last year's price still applies, is the only way to know before the pharmacy tells you.
If I keep the same plan, will my copays stay the same too?
Not necessarily. A plan's drug list is rebuilt every year, and a medication can move to a different tier — and a different copay — even when the plan itself doesn't change.
What is a formulary tier?
It's the category a covered drug is sorted into, generally ranging from lower-cost generics to higher-cost brand-name and specialty drugs. The tier determines what you pay, not just whether the drug is covered.
When is the new formulary available to check?
Plans generally publish the coming year's drug list before it takes effect on January 1, which means it can be checked during Medicare's Annual Enrollment Period, October 15 through December 7.
Does a tier change mean my drug is no longer covered?
No. A tier change means the cost category changed, not that coverage ended. The drug can still be covered — just at a different copay than the year before.
Questions about your own situation?
Free, no-obligation plan review — bring your medication list and we'll check every drug against next year's formulary.
Request my free plan review