Medicare Questions & Answers: Prescription Drug
Prescription Drug Q&A
Showing 32 questions
Why is the new $2,000 out-of-pocket maximum for drug costs important?
The $2,000 out-of-pocket maximum is a significant improvement for those who rely on expensive medications. After reaching this threshold, all additional drug costs will be fully covered by your Medicare Part D plan for the remainder of the year. This means that, for the first time, Medicare enrollees can predict and limit their annual prescription drug spending, offering peace of mind and financial predictability.
How do discount cards and resources affect my Medicare Prescription Drug plan?
If you choose to use a discount card to pay for a prescription because it's cheaper than the Medicare Prescription Drug plan, you can use it for the cheaper price. However, it will not count towards your out-of-pocket expenses.
How will the new 2025 Medicare Part D out-of-pocket cap impact seniors and prescription drug costs?
The new 2025 Medicare Part D out-of-pocket cap is a HUGE WIN for seniors! It limits how much they have to spend on prescriptions, making medications more AFFORDABLE, PREDICTABLE, and way less stressful.
I’ve been on a Part D plan for a while, and I’m wondering why my generic prescriptions suddenly cost more. Did something change?
Your generic prescription costs might be rising because Part D plans update their formularies, premiums, and copays each year, and I’ve seen many people overlook the need to review these changes annually. In my view, it’s a frequent mistake—failing to reassess coverage as costs and policies can shift significantly, especially this past year with the Biden-Harris Inflation Reduction Act taking effect. The Act introduced a $2,000 out-of-pocket cap for 2025, but it also altered how plans and manufacturers share costs, which can increase generic prices depending on your specific plan’s structure.What imbalance exists in prescription drug spending, and how has it impacted overall costs?
A recent report highlighted a stark imbalance where generic drugs, despite being 91.5% of prescriptions, only represent 12.9% of the drug spending, while brand-name drugs, at 8.5%, account for 87.1% of costs. This disparity contributed to an 11.4% increase in drug spending, reaching $450 billion, primarily due to rising costs for treatments of diabetes and obesity.
For Medicare Part D, why would someone pick a plan with a high total cost?
Beneficiaries need to verify that their drugs are on the formulary. Is their a drug deductible? What are the copays for their specific drugs? IF you medication is not on the $0 premium RX plan,that becomes a VERY expensive mistake. One that will cost them more than a high premium.
I have multiple medications; how can I ensure my Medicare Part D plan covers them all without breaking the bank?
medicare.gov has a public website allowing you to input your Rx list including name of drug, milligrams and dosage. Then key in your pharmacy preference to see which Medicare Part D plan will give you the best bang for your buck.
Why might Original Medicare with a Part D plan be better than a Medicare Advantage plan for frequent travelers?
It really isn't since original Medicare only pays 80%, the member is responsible for 20% of everything which can become costly. and you have to PAY for Part D every month & pay for your medication. A Medicare Advantage Plan includes drug coverage with Tiers 1 & 2 usually $0 costs , depending g on the plan
What are some ways to save on prescription drug costs?
If your plan doesn't cover your meds well, you can use a discount card like GoodRx or Singlecare. You could also search online for online pharmacies that can save you money like Cost Plus. You may also qualify for "extra help" from Medicare, or get help from the manufacturer or through a foundation.
How do I compare Part D plans to minimize costs for a mix of generic and specialty drugs?
Complete my survey including drug list and dosge. I can shop all drug plans by total cost(premium, deductible and copays)
I'm worried about the 'donut hole' in my Part D plan. How do I manage my medication costs once I enter it?
Don't worry! The dreaded "donut hole" has been discontinued effective January 1, 2025. So you can not longer enter the donut hole. However, Medicare pays less to the insurance companies this year for your prescriptions so most Part D plans now have higher deductibles which will be offset by a $ 2,000 annual limit on the full price of a member's covered Rx costs, so members with expensive name brand drugs will be protected by the new rules. Be careful on this and make sure that all of your prescriptions are in fact covered by your Part D plan.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?
In 2025, single tax filers making up to $ 1,976 monthly gross income with no more than $ 17,600 in assets (couples: $ 2,665 / $ 35,130) should qualify for Extra Help for Medicare Part D also referred to as LIS (Low Income Subsidy). To apply for help, go to ssa.gov/extra help, call Social Security at 800.772.1213, or call your local SS office. Walk in traffic is not recommended.
My diabetes medication is super expensive, and I've heard horror stories about Part D not covering what people need. Should I go standalone Part D or get it through a Medicare Advantage plan?
A knowledgeable broker, such as myself, will gather your prescription list and preferred pharmacy and help you compare standalone and Medicare Advantage drug plans. In my experience, these days, the MA plans are usually a little less expensive when compared with PDP plans all things being equal.I just started on Medicare Part D, and I’m confused about whether my new cholesterol medication counts toward my coverage gap. Can you explain?
Figuring out how your new cholesterol medication fits into Medicare Part D’s coverage gap can be confusing—it does count toward that limit, depending on your plan’s formulary and annual drug spending. In 2025, once your total costs hit the gap, you’ll reach catastrophic coverage after $2,000 out-of-pocket, lowering your costs to zero for covered meds, and Medicare now sends a statement detailing these expenses to keep you informed. Check that statement or your plan’s formulary for a clear snapshot of your progress!I'm getting conflicting information about whether Medicare covers my specific medication. How can I get a definitive answer?
This is why it is so important to actually meet with an agent in person who has several carriers they write for. The agent can put the members in the carrier's formulary to make sure the medication is coveredSo I heard something about Medicare drug costs being capped at $2,000 in 2025. Is that really happening or just talk?
It's really happening. There is a $2000 out of pocket limit for prescriptions that are on your plans formulary. The cap will cover deductibles, copayments and coinsurance but not the plan's monthly premium. Sometimes you'll see more prescriptions you take covered on higher premium plans. In this case you'd have the plan premium and then the $2000 out of pocket limit.Can Medicare Part D deny coverage for a brand-name drug if a generic isn’t available?
Medicare Part D can’t deny coverage for a brand-name drug just because a generic isn’t available—plans must cover it if it’s on their formulary and medically necessary, based on your doctor’s prescription, though they might require prior authorization or step therapy to justify it over other options. Upon enrollment, I always encourage my clients to call me if their medication regimen changes during the year so we can verify coverage details with the carrier and avoid surprises. I’ve dealt with this plenty, and as long as the drug’s listed and no generic exists, your plan has to honor it under CMS rules, but check your formulary or call your provider to confirm it’s not excluded or restricted. If it’s off-formulary, you’d need an exception, which can be a hassle but doable with your doctor’s help.How will the Inflation Reduction Act’s Medicare drug pricing changes really affect seniors?
The Inflation Reduction Act (IRA) brings real relief to seniors by capping your annual Part D out-of-pocket drug costs at $2,000 starting in 2025, eliminating the coverage gap and making prescription expenses much more predictable. What’s less obvious is how temporary premium stabilization credits are keeping Part D premiums low in 2025—once these fade, premiums could climb higher than they might have without the law, possibly offsetting some of your savings down the line. While drug companies now pay penalties for steep price hikes, which helps lower certain copays, I genuinely recommend watching your plan’s premium changes since these credit details weren’t fully emphasized when the law took effect.I've been dreading hitting the donut hole each year. How will its elimination in 2025 change what I pay throughout the year?
With all the 2025 Medicare Plans & Prescription Drug Plans, once a person reaches $2000 in cost including 25% of the drugs cost towards the $2000, there is no more costs to the member, therefore, no more "donut hole"I have Original Medicare, a Medigap Plan G, and a Part D plan, but I'm still facing high costs for my specialty medication. What options exist for someone in my situation?
Make sure that your Part D plan has the best possible coverage for your specialty medication. All plans are different and some will cover your specialty meds better than others.
I'm confused about the different tiers in Medicare Part D plans. How do they affect what I pay for my medications?
Medicare Part D drug tiers are the drug manufacturers' way of controlling costs. It is extremely important to make sure that your drugs are in the formulary, and these tier structures change annually. All Medicare Part D stand-alone drug plans and the Part D drug plans embedded in the Medicare Advantage plans must be analyzed yearly to ensure that you have the proper plan to cover your prescription drugs. Many drug plans utilize the tier structure to determine whether to allow the drug to be used towards the annual deductibles of that drug plan; this should be paid special attention to when selecting a drug plan.My pharmacist mentioned the Medicare "donut hole" is going away in 2025. What does that actually mean for me?
The "donut hole" (or coverage gap) in Medicare Part D prescription drug coverage is being eliminated in 2025, meaning once your out-of-pocket costs reach $2,000, you won't pay anything for covered medications for the rest of the year.
Does Medicare cover Ozempic and other drugs prescribed for weight loss?
It is coverage but not for weight loss yet. The drug may be covered with prior authorization. It is covered for type 2 diabetes.I'm caring for my dad who has Alzheimer's with lots of medications and I keep getting bills I don't understand. Any tips for not drowning in paperwork?
It is difficult to answer this questions as there is NO information on what type of paperwork you are having difficulty with. A good agent , like myself can help a member navigate the challenges of bills/ co pay/ co insurances with Medicare
How does the Part D “catastrophic coverage” phase work once I hit the out-of-pocket max?
If you have met the "catastrophic coverage" phase, you will have no further responsibility towards drugs covered in your plan's formulary. However, if you are on medications not covered by your Part D prescription drug plan, you will still be responsible to pay those costs.
I'm a low-income senior who can't afford my prescription drugs even with Medicare Part D. What specific assistance programs should I apply for?
You may be eligible for Extra Help, also known as Low income subsidy from Social Security.You can apply online here: https://www.ssa.gov/medicare/part-d-extra-help
My pharmacist mentioned the Medicare "donut hole" is going away in 2025. What does that actually mean for me?
The donut hole has disappeared as of 01/01/2025.Your yearly out of pocket prescription costs are capped at $2,000.
My friend says the new Medicare drug payment plan in 2025 will help with her expensive medications. Would it help me too?
It's possible. It depends on the particular medications you take and what your overall projected expense will be. The Medicare Prescription Payment plan (M3P) will go a long way to making monthly prescription pickups more balanced. For instance, instead of paying $590 for the first pick up of the year, M3P can average out the annual cost and may make the first pickup in the range of $180. You must talk to your insurance plan to trigger M3P prior to making the first prescription purchase of the year.
My doctor wants me to use a smartphone app for medication management and adherence. Are there any Medicare programs that support this type of digital health solution?
I believe there are many ways to do this. Simplest way is to set an alarm in your phone for daily reminders.So I heard something about Medicare drug costs being capped at $2,000 in 2025. Is that really happening or just talk?
It's very real. Medicare members are capped when your Part D or C plan's actual retail cost of covered drugs reaches $ 2,000 during 2025. Be sure to confirm that all of your meds are listed as "covered" drugs. Check your plan's formulary for that.
What is the main benefit of Medicare Part D?
Co-pays (although not always) are better than the discount cards. The problem is that the government tells you if you don’t get Part D,when eligible, then you’ll be penalized should you want one later and the penalty is forever. That is just wrong. So that is the two reasons to have one. The drug card that is part of Part C Medicare AKA Medicare Advantage plans has no premium associated with that program.
What’s the biggest mistake seniors make when choosing a Medicare Part D plan?
Hello ,On the Part D, (Prescription drug coverage).
I get a list of your prescriptions you are currently taking, then I go to the Medicare.gov
I check what plans cover the drugs and the pharmacies at the lowest cost, so you can get the best prices and control the budget for your cost for the year!
It is best to check all your cost at the pharmacy you use, (it might be costing you a lot, or it might be the best, the Medicare.gov site lets you know, call me, I can help!
Thx!