Patient Assistance Programs: Real or Scam?
Medicare beneficiaries are struggling to pay for their brand (tier(s) 3, 4, 5) medications, especially considering "The Inflation Reduction Act's" disastrous changes in 2025 to the Medicare Part D Program.
That has more and more people asking about Patient Assistance Programs, or PAPs. Are they real? Are they a scam? Can they actually help?
Legitimate PAPs do exist, and they can save real money on brand-name medications. But not everyone qualifies, and not all programs are created equal. Here's what you need to know.
Why Brand-Name Drugs Cost So Much Under Medicare Part D
Even though there is now a Maximum Out of Pocket (MOOP) of $2,100 (proposed $2,400 in 2027) for "drugs (only) on their formulary", most health plans have chosen to add a deductible of up to $615.00 in 2026 (proposed $645 in 2027) and raised their Tier 3, 4 & 5 copay/coinsurance.
What is not accounted for in the MOOP is the Premium costs (associated with standalone Part D) which can be greater than $100.00/month ($1,200/year) and the health plan's restrictions on brand medications when the doctor orders and prefers them.
A Real-World Example: What Eliquis Costs on Medicare
Eliquis has a list price of $550 for a 30-day supply. At 24% coinsurance, like some health plans have adopted, that costs $132 for 30 days or $396.00 for a 90-day supply.
If a drug is not on the formulary of the plan, then there is no maximum $$$ relief. Some Brand Meds like Trulicity, Farxiga, Humilog, Jardiance, Cancer drugs, may not be covered.
Suppose your doctor wants you on a certain brand Rx and your plan won't approve it? What can you do?
Medicare Assistance Is Limited to Lower Income
There are many types of assistance for the cost of prescriptions in healthcare. However, Medicare is unique. The problem for all middle-income Medicare eligible families is that the Medicare assistance program is only for Lower Income folks. It's called LIS or Low-Income Subsidy, aka "Extra Help".
LIS artificially lowers the Rx copay costs of beneficiaries with annual incomes that are below $23,475 (single) and $31,725 (household) with also a limit on asset value. For more on Extra Help and other Medicare savings programs, check out our detailed guide.
I'm on a fixed income and struggling to afford my medications. What's this Extra Help program I've heard about for Medicare Part D?
Hello and thank you for our question… Medicare Low Income Subsidy or LIS is also known as Extra Help. This program is meant for individuals or couple who have incomes below a given threshold (which amount is modified each year). In 2025 for individuals that amount is: $23,725 and for a Married couple the amount is $31,725.So, what do Medicare recipients do if their income is over the above amounts and we need Brand Name Meds either not on the formulary or subject to huge deductibles, copays and premiums...? If you are not on a PAP, you pay the cost or you don't pick up and take the meds.
What Is a Patient Assistance Program (PAP)?
PAPs are designed by manufacturers to help folks afford costly medications. Most TV drug ads we see have a small note to inform the watcher that the manufacturer can get you help to afford their very expensive medication.
If you can find one, those programs are replete with 6-10+ pages of documentation and submission. You can request information from your doctor or call the manufacturer to find one of these programs, but it's hit and miss at best.
Smart Save Meds PAP
How It Works
For over 22 years, they have served over 1 million clients. Recipients must qualify and pay reasonable ongoing subscription fees; the vendor completes all the paperwork and coordinates with your doctor(s).
If accepted, the member is entitled to receive, directly from the manufacturer, unlimited 90-day supplies of their Brand Meds for $0 copay each.
Who Qualifies?
To qualify, the recipient(s) needs to be on Social Security and Medicare A&B (and/or Part C) and not on Medicare Extra Help. This has no impact on their Medicare, or their choice of doctor or health plan.
They continue to get generic drugs through their health plan's (PDP), prescription drug plan.
What Can You Do Now?
Investigate options with a PAP. Your Health & Wealth may be better if you do!
About the Author: Greg Firmbach is the principal of AEGIS Elder Advisors, Home of GREG The Medicare Guy. A financial services and Medicare Consulting Firm whose main product is "Peace of Mind" utilizing Retirement Transition Planning. AEGIS is a Veteran and Women Owned Business. Help comparing insurance plans or understanding policy terms? We're happy to walk you through it. Appointments are conveniently scheduled at your home, at the local CVS in Parrish, any public venue (even Beef O Bradys, Butterfield's or Applebee's), phone or Zoom... your choice.