Why do 1 of my prescriptions have a regular copay, and then my preferred one needs to be paid in full to reach my $500 deductible?

Hey All,

I have been taking weekly testosterone injections for 4 years. I began to get horrible needle anxiety, so tried out the gel and it just didn't work out. There was a new company, named Xyosted, that prescribes you your dosage of testosterone in an auto-injector, it almost looks like an epipen. This was a non-formulary drug under my plan, but my doctor sent a prior-authorization anyway saying I had tried all the other options and it was accepted within a week.

I've been on this for 6 months, and it has been AWESOME! Suddenly, over a month ago the pharmacy called me and said my co-pay that was originally $30, was full price $450. I called my insurance, and they said their year has ended and now I have to reach my deductible of $500, and that the good thing was that this medicine was making me reach my deductible immediately. The thing was, I never remembered earlier last year ever getting hit by a big bill to reach my deductible.

I knew the testosterone regular injections (vial, needle, then self injection) would only cost me less than $100 with a goodrx coupon, so I asked for a new prescription of that from my doctor. I went to pick it up with a goodrx coupon handy, and before I could even show it, the pharmacist only asked for a $10 copay. I'm not sure if this matters, but the testosterone cypionate regular injections are a Tier 2 drug on my insurance.

I am so confused! If I need to reach my deductible.. why do I need to pay full price for Xyosted, yet the regular testosterone cypionate is just my usual $10 copay? Idk if the below will be any help, but this is what the website says.

Tier 1: Generic drugs in the Adherence Drug Program
Tier 2: Generic drugs not included in the Adherence Drug Program
Tier 3: Preferred Brands
Tier 4: Non-Preferred Brands
Tier 5: Preferred Specialty Drugs
Tier 6: Non-Preferred Specialty Drugs
Tier 0: Affordable Care Act Preventative Drugs

and then below this was just "Non-Formulary" as the last option, no tier.

Xyosted was "non-formulary", the regular testosterone was tier 2.

I have horrible anxiety in general and I have no idea how to word my question if I were to call my insurance and ask them. I just wanted to understand more behind how my insurance works!

submitted by /u/heckyeahtoast
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