The cost of prescription drugs has been generally increasing for decades, and the average price increased by more than 200% just between 2006 and 2017. Seniors make up just 16.5% of the population of the United States, but they consume more than 34% of the medications doctors prescribe. Older adults pay more than half of their drug costs out of pocket, with prescription-related expenses being especially high for seniors with chronic conditions.
Seniors have options for managing the cost of their prescription drugs. No single solution pays all of the costs, and many seniors have to pull together several resources to keep this part of their health care expenses under control. In this guide, we go over some of the most common approaches to paying for the cost of prescription drugs. By the end of the article, you should have several options that can help you out with financial assistance for prescription drugs, and many can help with other medical expenses you might be struggling with.
Prescription Drug Coverage Under Original Medicare
Medicare is the first place most seniors turn to for help paying for prescription drugs. If you have Original Medicare, your prescription drug benefit is covered under Part D. Part D coverage is optional, but the benefits include partial coverage for both brand-name and generic prescription drugs. All approved Part D plans, which are issued through participating private insurers, must provide coverage for at least one drug in every Medicare-mandated category. However, each plan can vary a bit in the exact medications it covers.
If you participate in Original Medicare, you can sign up for Part D by purchasing coverage through a provider authorized in your state. All plans come with a premium, which is the amount of money you have to pay each month, plus a share of cost. The average premium for Part D plans in 2022 is $43 a month. The share of cost is the amount of money you are expected to pay yourself before your insurance coverage kicks in. You may have to pay a certain dollar amount out of pocket before your coverage begins, which is called a deductible. This amount varies from one plan to the next. In 2022, the maximum deductible is $480 for the calendar year.
You could incur additional costs if you don’t sign up for Part D when you’re eligible, so carefully consider your options before your eligibility period starts.
Do You Qualify for Part D?
Medicare Part D plans are not open to everybody. If you are 65 or older and you either receive or are eligible to receive benefits from Original Medicare or Social Security, you are probably eligible for a Part D plan also. You may not enroll in a Part D plan if you are also enrolled in a Part C plan, sometimes called Medicare Advantage, which is already likely to include a prescription benefit.
Extra Help is a program for Part D enrollees who need financial assistance for prescription drugs that goes beyond the regular Part D benefit. If you meet the program’s income guidelines, Extra Help can pay down your copayment and other costs to further reduce the out-of-pocket expenses your prescriptions impose. In 2022, this benefit is worth $5,100 for each beneficiary.
You can apply for Extra Help online through the SSA web portal or over the phone by calling (800) 772-1213. To apply for Extra Help in person, speak with your case manager, social worker or the benefits coordinator at your residential facility. You can also apply by appointment at your local Social Security office.
No matter how you do it, applying for Extra Help can get complicated. This helpful list has tips for submitting a successful application and getting the fastest possible decision.
Appealing a Denial for Extra Help
If your claim has been denied for any reason, you likely have a right to appeal the decision. Denials for coverage are unfortunately common, and they are not always the right decision. You might have your claim denied because of a simple mistake or because of confusion about your location or supplemental insurance status. In many states, for instance, Medicaid beneficiaries are not eligible to participate in Extra Help, but it is possible to access both in other states, such as California.
If you get a notice of denial from the Social Security Administration, it will contain information outlining your rights to an appeal, deadlines you have to meet to file your case and contact information for the process. You or your caregiver can appeal the decision by filling out and submitting this form.
Prescription Drug Coverage Under a Medicare Advantage Plan
Medicare Advantage is an alternate way to get Medicare benefits. These plans are issued by private insurers that are authorized to bill the Medicare program on your behalf, and many of them offer outstanding group rates for seniors. By law, all Part C plans must offer the same coverage as Medicare Parts A and B, which can be folded together into a single plan with a monthly premium that might be as low as $0. Many Medicare Advantage plans also offer some benefits not available under Original Medicare, such as vision and dental coverage, as well as a prescription drug benefit that might meet or exceed your Part D benefits.
Because plan details vary between providers and between states, there is no easy summary of your prescription drug benefits under a Part C plan. It is a good idea to research all the plans offered in your area before committing to an option, which may be done during the annual open enrollment period between October 15 to December 7 each year. You are also free to enroll in Part C when you first become eligible for Medicare, regardless of the time of year, or during a special enrollment period, which starts after you have a qualifying life event, such as losing prior coverage through no fault of your own or returning to the country after an absence.
Medicare Supplemental Coverage
If you are enrolled in either Original Medicare or a Part C plan and find that your drug costs are still too high, you’re not alone. It is very common for seniors who need extra financial assistance with their health care costs to carry a special supplemental policy that’s designed to mesh with Medicare benefits to provide better overall coverage. You can get this extra protection from a few sources.
Medicaid as a Medicare Supplement
About 19% of all Medicare enrollees are eligible for full or partial Medicaid coverage as well. Seniors who qualify for both programs are sometimes called dual-eligible, and they can use Medicaid benefits as an outstanding supplement for managing Medicare’s out-of-pocket costs.
If you are dual-eligible, you can integrate Medicaid into your coverage profile just like a standard Medicare supplemental policy. The exception is that your Medicaid coverage is likely to be less expensive, perhaps even free at the point of service, and cover a fairly exhaustive list of medical needs. Medicaid policies vary from state to state, but generally, the program will pay the uncovered costs for medically necessary drugs, equipment and procedures. You must have a doctor authorize your treatment to be covered by Medicaid, and you could still have to meet a share of cost that depends on your financial position.
To qualify for Medicaid, you must be a citizen or permanent legal resident of the United States and a permanent resident of the state where you are applying for benefits. An intake worker will examine your financial documents to make sure you meet the program’s income and asset limits for providing coverage. These numbers vary from state to state, but the maximum income limits tend to be higher in states with a high cost of living.
Medicaid Prescription Drug Coverage
Medicaid coverage for prescription drugs can get complicated, but in most states, the aim of the program is to make it fairly simple for you to use when you go to pick up your prescription at the pharmacy. Federal laws governing Medicaid effectively require each state to maintain an open formulary. In theory, this means they can help you pay for any medically necessary drug your doctor prescribes. In practice, most states’ Medicaid programs try to limit costs by creating a preferred drug program that prioritizes generic and other low-cost options before switching to brand name and experimental drugs.
Your doctor and the staff at the medical office or pharmacy can probably help you find adequate drug options that your Medicaid benefits will cover, but even very costly drugs may be included in your Medicaid benefits if there is no other option.
To use Medicaid at the pharmacy, you generally only have to present the benefits card that identifies you as a beneficiary at the time of payment. Your pharmacy will always bill your Medicare program first, with the unpaid costs shifting over to your Medicaid plan. If you have an annual spend down, share of cost or copayment requirement under Medicaid, you may have to pay that amount out of pocket at the time of service.
Patient Assistance Programs (PAPs)
If your Medicare, Medicaid and/or supplemental insurance are not enough to cover the cost of your prescription drugs or you don’t have full coverage for whatever reason, you’re not out of luck. Many states operate some kind of prescription assistance program (PAP) that can help out with the high price of necessary medications. These programs are certified by the Center for Medicare/Medicaid Services (CMS) for assisting seniors with their Part D copayments and uncovered drug costs.
PAPs are not just government programs. These are discounts offered directly from pharmaceutical companies for low-income patients who need medications they can’t afford. Companies offer PAPs for various reasons that range from a sense of social duty to good marketing and convenient tax benefits. In practice, these programs operate basically like special coupons that can see you getting the medicine you need at a greatly reduced cost — or even for free.
There are hundreds of PAPs operating in the United States. Surprisingly, your doctor may not be the best source of information about these programs. It is not very often that pharmaceutical companies include PAP information in their updates to medical providers, so many doctors have limited experience with these kinds of discounts. You can look up various PAPs online by searching through databases of drug manufacturers, the generic and brand name medications they offer and finding the ones you need. If you can find a PAP that covers one or more of the prescriptions you’re currently getting, you can apply for a discount card from the program. Present this card when you go to fill your prescription, and the discount will be applied at the register.
PAPs are not for everybody. Your particular drugs may not be covered, for instance, in which case you will either have to switch to a covered alternative or go without the discount for the time being. Many PAPs have an income and insurance coverage limitation, which you have to meet before you can sign up for the discount card.
Examples of Drug Company Assistance Programs
Many of these programs cover specific drugs, but others help out with multiple medications offered by the company. Coverage may be limited, and enrollment may be subject to income limits and Medicare/Medicaid enrollment status.
|Company||Contact||Open to Medicare/Medicaid Enrollees?||Program Details|
|AstraZeneca (Pulmicort, Symbicort, Fasenra)||(800) 292-6363||Yes||Copayment support and drug assistance|
|Genentech and Novartis (Xolair)||(888) 941-3331||Yes||Copayment support and drug assistance|
|GlaxoSmithKline (GSK) (Advair, Flovent, Serevent, Ventolin)||(888) 825-5249||Medicare participants only||Open to Medicare enrollees with no prescription drug support at all|
|Merck Helps (Asmanex, Dulera, Nasonex, Proventil, Singulair)||(800) 727-5400||No||Copayment support and drug assistance|
|Mylan (EpiPen, generic epinephrine auto-injector)||(800) 796-9526||Yes, for enrollees without current drug coverage||Direct assistance|
|Pfizer||(844) 989-7284||Yes, for enrollees without current drug coverage||Copayment support and drug assistance|
|Sanofi (Dupixent)||(844‑387‑4936||Yes, if Dupixent is not covered||Copayment support|
|Teva Pharmaceuticals (QVAR)||(877) 237-4881||Yes, for enrollees without current drug coverage||Copayment support and drug assistance|
Other Options for Prescription Drug Costs
No matter what your insurance and PAP situation happens to be, you can still limit your out-of-pocket expenses by shopping around and trying to lower the point-of-sale costs for the drugs you need to stay healthy. There are several ways to do this, and not nearly enough seniors are using them all. Regardless of your financial status, or whether you have excellent, mediocre or nonexistent prescription drug coverage, these tips can help you shave down some of the expense of keeping your prescriptions filled:
Many drug manufacturers offer coupons for their products, just like any other producer of a product you buy in the store. Sometimes, these coupons are available online directly from the manufacturer, but others are paper vouchers your doctor has in the office. These can be a great marketing tool for many pharmaceutical companies, so they tend to offer steep discounts on new brand-name drugs, as well as for products that have soon-to-expire patents. Check your drug companies’ websites and social media feeds for news about promotions and discounts, and sign up for email and other updates in case a prescription you need goes on sale or has a coupon issued.
Switching to Generics
Brand-name drugs can be very expensive. As a rule, the company that develops a new drug has a 10-year window when only they have the right to produce the medication. Other companies might also produce the drug, but they do so under license and generally have to pay a substantial share of the revenue to the original manufacturer. This is done to protect the companies developing new treatments and to encourage continued innovation. It can, however, substantially drive up the cost for your prescriptions.
If it is at all possible to safely do this, ask your doctor about switching from pricey brand name drugs to much more affordable generics. The patent typically runs out on new drugs after 10 years, after which any drug company is free to manufacture the same product. By law, these generic drugs must be identical to the original medication, right down to the molecule, so you’re generally safe if you need to switch. All the same, always ask your doctor about switching before you do it. You will need a new prescription to get the new medication, and your doctor may have good reasons for preferring the brand-name drug over the competing generic brand.
State Discount Cards
Many states offer drug discount cards for seniors, adults with disabilities, needy children and other people who struggle to pay for prescription drugs. In many cases, these discount cards are available for people with specific conditions, such as diabetes or kidney failure, while others are open to any state resident who needs the financial help. Rules for how to qualify, acquire and use a discount card vary from state to state, and your state might not even offer a discount. Check your state’s health and human services website, or talk to a case manager at your local human services office about the options that may be open to you/
Shopping online for anything can save you a lot of money. This is also true for prescription drugs. In recent years, the world of safe, affordable online pharmacies has exploded on the internet. While each operates as its own company, they generally work the same way. Once you pick out your drugs from the available list on their websites, you can forward your doctor’s prescription over to authorize dispensing the medications. Generally, a package with your meds should arrive in a few days.
Pharmacy Drug Savings Programs
In addition to drug companies, pharmacies themselves offer some support for seniors with limited resources to get the medications they need. These pharmacies offer discount and assistance programs for all or most of their customers. Most programs are free of cost, but some are membership clubs that charge monthly fees. Some area-specific limits exist, and not all medications are covered. Some programs are limited in their coverage for Medicare and Medicaid enrollees.
|Pharmacy||Contact||Open to Medicare/Medicaid Enrollees?||Cost to Join||Notes|
|Blink Health||(844) 792-6701||Yes||Free||Discounts on selected prescription drugs|
|Good RX||(855) 268-2822||Yes||Free||Basic assistance is free, but GoodRx Gold is an optional upgrade available for a monthly fee|
|Kroger RX Savings Club||(855) 912-6346||Yes, but benefits cannot be combined with federal or state-funded programs such as Medicare Parts C or D, or with Medicaid||Individuals pay $36 a year. Families with up to six members pay $72.||Not available in Washington state locations|
|Publix – Chronically Free/Next Best Thing to Free||Local Publix pharmacy||Yes, but details vary by location||Free||Selected medications are offered for free or at $2.50 a month with a doctor’s prescription|
|Walgreens Prescription Savings Club||(866) 922-7312||No||Individuals pay $20 a year. Families pay $35.||Includes Duane Reade locations. Some stores in Connecticut, Massachusetts, Mississippi, Washington, Missouri and South Carolina do not participate in the program.|
|Walmart $4 Prescriptions Program||Local Walmart pharmacy||No||Free||Medicines are available for $4 a month or $10 for a three-month supply. Note that some North Dakota locations do not participate in the program.|
Nonprofit Copay and Premium Assistance Programs
Nonprofit organizations commonly help seniors and adults with limited resources get needed prescription medications. Some of these programs are privately operated charities, but some are sponsored by businesses and others are administered by state and local governments. Because of the diversity among these assistance providers, you might find a wide variety of coverage limits, eligibility requirements, geographic restrictions and plan details. Some programs are open to Medicare and Medicaid enrollees, while others are not or may be limited in how much they can help people with Part D or Medicare Advantage. Many programs have special funds to help with the cost of asthma medications, which are separately listed for clarity and convenience.
|Program||Contact||Open to Medicare/Medicaid Enrollees?||Assistance for Asthma?||Notes|
|Good Days||(877) 968-7233||No||No||Copay, travel, premium and diagnostic testing assistance is available for eligible enrollees.|
|Extra Help (Social Security Administration)||(800) 772-1213||Yes||Details vary||Enrollees must receive Medicare, live in one of the 50 states or territories, have limited resources and need assistance with copayments. SSI and dual-eligible beneficiaries may not be eligible for Extra Help.|
|Healthwell Foundation||(800) 675-8416||No||No||N/A|
|Partnership for Prescription Assistance||(888) 477-2669||Details vary by program||Yes||N/A|
|Patient Access Network Foundation||(866) 316-7263||Yes||Varies by specific brand||Copayment, insurance premium and travel assistance are available.|
|Patient Advocate Foundation||(866) 512-3861||Yes||No||Beneficiaries must have Medicare, Medicaid or military (VA) benefits that can be applied to the medication prescribed.|
|Patient Services Incorporated||(800) 366-7741||Yes||Yes, with limits||Copayment, insurance premium and travel assistance are available.|
|Rx Outreach||(888) 796-1234||Yes||Yes||Discount program is available for asthma medication and selected other drugs.|
|RxAssist Patient Assistance Program Center||Online only||Details vary by program||Details vary by program||N/A|
|State Health Insurance Assistance Programs (SHIPs)||(877) 839-2675||Yes||Details vary by program||No-cost counseling and case manager services help locate and apply for prescription drug benefit programs.|
|State Pharmaceutical Assistance Programs||Online only||Yes||Details vary by program||N/A|
|The Assistance Fund||(855) 845-3663||Yes||No||Assistance is available for copayments, coinsurance requirements, insurance premium costs, deductibles and incidental expenses.|
Financial Assistance for Prescriptions in Your State
Find your state below to read a comprehensive guide to the financial assistance resources for medications that may be available to you.
Guide to Financial Assistance for Prescription Drugs in California
Guide to Financial Assistance for Prescription Drugs in Texas
Guide to Financial Assistance for Prescription Drugs in Florida
Guide to Financial Assistance for Prescription Drugs in New York
Guide to Financial Assistance for Prescription Drugs in Pennsylvania
Guide to Financial Assistance for Prescription Drugs in Illinois
Guide to Financial Assistance for Prescription Drugs in Ohio
Guide to Financial Assistance for Prescription Drugs in Georgia
Guide to Financial Assistance for Prescription Drugs in North Carolina
Guide to Financial Assistance for Prescription Drugs in Michigan
Guide to Financial Assistance for Prescription Drugs in New Jersey
Guide to Financial Assistance for Prescription Drugs in Virginia
Guide to Financial Assistance for Prescription Drugs in Washington
Guide to Financial Assistance for Prescription Drugs in Massachusetts
Guide to Financial Assistance for Prescription Drugs in Tennessee
Guide to Financial Assistance for Prescription Drugs in Indiana
Guide to Financial Assistance for Prescription Drugs in Missouri
Guide to Financial Assistance for Prescription Drugs in Maryland
Guide to Financial Assistance for Prescription Drugs in Wisconsin
Guide to Financial Assistance for Prescription Drugs in Colorado
Guide to Financial Assistance for Prescription Drugs in Minnesota
Guide to Financial Assistance for Prescription Drugs in South Carolina
Guide to Financial Assistance for Prescription Drugs in Alabama
Guide to Financial Assistance for Prescription Drugs in Lousiana
Guide to Financial Assistance for Prescription Drugs in Kentucky
Guide to Financial Assistance for Prescription Drugs in Oregon
Guide to Financial Assistance for Prescription Drugs in Oklahoma
Guide to Financial Assistance for Prescription Drugs in Connecticut
Guide to Financial Assistance for Prescription Drugs in Utah
Guide to Financial Assistance for Prescription Drugs in Iowa
Guide to Financial Assistance for Prescription Drugs in Nevada
Guide to Financial Assistance for Prescription Drugs in Arkansas
Guide to Financial Assistance for Prescription Drugs in Mississippi
Guide to Financial Assistance for Prescription Drugs in Kansas
Guide to Financial Assistance for Prescription Drugs in New Mexico
Guide to Financial Assistance for Prescription Drugs in Nebraska
Guide to Financial Assistance for Prescription Drugs in West Virginia
Guide to Financial Assistance for Prescription Drugs in Idaho
Guide to Financial Assistance for Prescription Drugs in Hawaii
Guide to Financial Assistance for Prescription Drugs in New Hampshire
Guide to Financial Assistance for Prescription Drugs in Maine
Guide to Financial Assistance for Prescription Drugs in Montana
Guide to Financial Assistance for Prescription Drugs in Rhode Island
Guide to Financial Assistance for Prescription Drugs in Delaware
Guide to Financial Assistance for Prescription Drugs in South Dakota
Guide to Financial Assistance for Prescription Drugs in North Dakota
Guide to Financial Assistance for Prescription Drugs in Alaska
Guide to Financial Assistance for Prescription Drugs in Arizona
Guide to Financial Assistance for Prescription Drugs in Vermont
Guide to Financial Assistance for Prescription Drugs in Wyoming