If you are unable to afford copayments for your prescription drug plan (with or without Extra Help)

Section IX.e. The Extra Help Program
Question 4 of 6 (use "Last" or "Next" buttons to see more)

If you belong to a Medicare private drug plan but cannot afford your medications under this coverage—whether or not you have Extra Help (federal assistance that helps with the costs of the Medicare drug benefit) or get help from a state prescription assistance program—there are a few options that might help, especially during your plan’s coverage gap (“doughnut hole”):

Ask your doctor...

  • About generics. Generic drugs are almost always less expensive than brand-name drugs and might be more affordable for you. In most cases, generic drugs work the same as the brand-name versions.
  • (Note: If you have Extra Help, taking more expensive brand-name drugs could get you to catastrophic coverage faster when you will pay less—see suggestion 7 below).

    • for samples of your medication. This is a temporary solution, as your doctor may not be able to provide samples for very long. While you are using the samples, you should explore other options for getting your drugs covered, such as asking for an exception (see suggestion 3 below) or switching drug plans.
  • If you have Extra Help, find out if your drug plan has a mail-order option.

    • If you have Extra Help, you may be able to get a 90-day supply of your prescription for the same amount of money that you would normally pay for a one-month supply.

    Keep in mind that with mail order, it will take longer for your drugs to reach you than if you were to go to the pharmacy yourself. You must plan ahead when filling your prescriptions by mail.

  • Request that your plan put your drug in a lower "cost tier" for you. To do so you will have to have your doctor submit a formal request to your plan to ask for an "exception" to the formulary.Be aware that you cannot ask for a "tier exception" when the drug you need is in a "specialty tier" (often the most expensive drugs); or you want to access a brand-name drug at the same copay tier as a generic drug.

  • Some pharmacies and hospitals will waive copays for people with low incomes.

    • Pharmacies are not allowed to routinely waive their copays for people with low income who do not qualify for Extra Help, but your pharmacist can waive copays on a case-by-case basis. Tell your pharmacist you cannot afford the copay and ask if he will waive it. If he will not, ask your friends if they know of a pharmacy in your drug plan’s network that will.
    • Some pharmacies routinely waive co-pays for people with Extra Help. Ask your pharmacist if your pharmacy does this.
    • The amount that the pharmacist waives for you may still count toward reaching your catastrophic coverage limit. Talk to your plan to see whether this amount will be counted.
    • Some hospitals have a Charity Care Policy that can reduce your drug copays if you cannot afford them. Your final copay will be based on a sliding scale (based on your income). To get help, you need to have a prescription written by a doctor in the hospital and then have that prescription filled in the same hospital’s pharmacy. Tell the hospital’s pharmacist that you cannot afford your copays and ask if you qualify for help paying for your drugs.

    Note: You should check with the hospital’s pharmacy to see if they are part of your Medicare private drug plan’s pharmacy network. If they are not, the prescriptions that you fill there will not count toward the $4,550 in out-of-pocket costs you must spend before you get catastrophic coverage (see number 7 below).

  • Some states offer pharmaceutical assistance programs that help their members pay the out-of-pocket costs of a Medicare private drug plan.
     


      Many state pharmaceutical assistance programs coordinate with the Medicare prescription drug benefit and help with the costs of Part D coverage (many of these states require you to get Part D). A few states have programs that do not require that you join Part D and offer good coverage that is creditable (at least as good as the Medicare drug benefit). You can delay in enrolling in the Medicare drug benefit without penalty in these states. Check out the MI Extra below to find out if your state has an SPAP and how it works.
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  • Some charities may pay a portion or the full cost of your Medicare prescription copays. Many of them help people with specific diseases. See the MI Extra for details.
  • Note: What these charities pay will count towards the $4,550 in out-of-pocket costs you must spend before you get catastrophic coverage (see number 7 below) as long as you go to a pharmacy in your drug plan’s network and are getting copay assistance for a drug on your Medicare drug plan’s list of covered drugs (“formulary”).

    The programs listed in the MI Extra will also help people who do not have a Medicare prescription drug plan.

  • Catastrophic coverage.

    • If you have Extra Help, as soon as your total drug costs reach $6,455.00 (what you pay plus what your drug plan pays for your covered drugs) catastrophic coverage will begin. Your total drug costs will reach $6,455.00 faster if you take more expensive name-brand drugs (for which you will pay $6.35 copays). Once you reach catastrophic coverage, you will no longer have copays. If you have partial Extra Help, your copays will go down from 15 percent or your plan's standard coinsurance (whichever is cheaper) to $2.55 for generics and $6.35 for brand-name drugs.
    • If you don’t have Extra Help, you will get to catastrophic coverage when you have spent $4,550 out-of-pocket on covered drugs in 2014. During catastrophic coverage, you will pay 5 percent of the cost of the covered drug, or a copay of $2.55 for generics and $6.35 for brand-name drugs (whichever is greater) . Only what you, your state pharmaceutical assistance program or a certified charity pays for drugs covered by your plan count towards the $4,550.

  • Some pharmaceutical companies have Patient Assistance Programs (PAPs) that offer low-cost or free drugs to people with low incomes. While many PAPs will not accept people with Part D, some do. If you are eligible for a PAP, your free or low-cost medication may be sent to your home, your doctor’s office, or a local pharmacy, depending on the program. You may be required to pay a co-payment. What you pay will count toward meeting your out-of-pocket limit ($4,550 in 2014). You will need to submit your receipts to your plan, and any other required documentation, in order for this amount to count towards reaching the limit. What your PAP pays for your prescription drugs will not count toward the $4,550 in out-of-pocket costs that you must spend before catastrophic coverage begins. So, you may stay in your Part D plan’s coverage gap longer if you use PAP assistance. If you are interested in a specific PAP, call the program to find out how it works.
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  • Prescription drug discount programs. You may be able to get reduced prices on the medications you need from national and local discount programs. You cannot use a prescription drug discount program and your Part D coverage at the same time. You will have to choose between them at the pharmacy.
  • If you have Part D, it is best to use your discount card only during your plan’s deductible and coverage gap periods. It is only during these times that what you pay for a drug on your Part D plan’s formulary (list of covered drugs) can count toward meeting your out-of-pocket maximum before catastrophic coverage begins. You will need to tell the pharmacist to refill your medication without using your Medicare drug coverage, and submit your receipts to your plan with any other required documentation, in order for this amount to count toward reaching the catastrophic coverage limit. Find out what your plan requires by calling the customer service number listed on the back of your Medicare drug plan insurance card.

  • Lower price at the pharmacy.

    • Promotional pharmacy price. If a pharmacy in your plan’s network has a special promotion ( limited time offer) to sell a medication that is on your plan’s formulary (list of covered drugs) for a cheaper price than your plan, you can buy the medication for this price. You will need to tell the pharmacist to refill your medication without using your Medicare drug coverage. It is best to take advantage of such specials only during your deductible or coverage gap because it is only during these times that what you pay will count toward reaching your plan’s catastrophic coverage limit. You will need to submit your receipts to your plan with any other required documentation in order for this amount to count toward reaching the catastrophic coverage limit. Find out what your plan requires by calling the customer service number listed on the back of your Medicare drug plan insurance card.
    • Pharmacy discount generic programs. Some retail pharmacies offer year-round discounts on generics. If a pharmacy in your plan’s network regularly sells a generic medication covered by your plan for a cheaper price than that offered by your plan, you can take advantage of this price at any time. If you normally pay a coinsurance, you will pay it based on the cheaper store price. For example, if your plan normally charges a full price of $10 for your drug, and you have a 25 percent coinsurance during your coverage period, with your Part D plan you would pay a $2.50 coinsurance. However, if a store (like Wal-Mart) offers the drug you need for $4, you should automatically be charged 25 percent of that $4 price, or $1. If you pay a copay, you will pay the pharmacy price or your copay, whichever is lower. The full cost of the drug (as set by the pharmacy), will count toward your plan’s catastrophic coverage limit. You should not have to submit additional paperwork.

 


Related Questions
Can my state give me more rights and protections than federal law regarding Medigap plan enrollment?

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GO TO
The doughnut hole

Changing your Medicare private drug plan (Part D)

Help paying for the Medicare drug benefit for people with low incomes (Extra Help)

When should I ask my Medicare drug plan to pay for a drug (ask for an exception)?

Does my state have a program to help me with my prescription drug costs?

 
LINKS
WorstPills.org Saving Money When Buying Prescription Drugs

National Association of Area Agencies on Aging (n4a)

State Health Insurance Assistance Program (SHIP) Directory

State Pharmaceutical Assistance Programs by State (Medicare.gov)

 
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