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?

Question

Charise Karjala · Accepted Answer

How Medicare Part D covers expensive medications:

Formulary:
Each Part D plan has a formulary (list of covered drugs) organized into tiers (generic, preferred brand, non-preferred brand, specialty drugs, etc.).
Expensive medications are usually placed in the specialty tier, which often has higher cost-sharing (a percentage, not a flat copay).

Cost Stages During the Year:
Part D plans have four payment stages each year:

Deductible Stage:
You pay 100% of your drug costs until you meet the deductible (maximum $545 in 2024; this may be slightly different in 2025).

Initial Coverage Stage:
After meeting the deductible, you pay a copay or coinsurance (often 25%) until total drug costs reach a certain amount (around $5,030 in 2024).

Clarence &quot;Mark&quot; Christiansen · Answer

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.

Lt Col Tim Brown · Answer

You can join your Part D plans prescription payment plan. They will divide the payments for meds out through the year. You can pay no more than $2,000 in a calendar year for all meds involved. Even if you we on 30 meds, $2k is the max you can pay. Another idea is get samples from the doc. Use discount cards to see if there Is actually savings there. Hope that helps.

Answered by Lt Col Tim Brown on April 29, 2025

Broker Licensed in TN, AL, CO & 10 other states

Answered by Lt Col Tim Brown Medicare Insurance Agent

Misty Bolt · Answer

Did you try the pharmaceutical company or the foundation. 340 B pharmacy might be able to help. Maybe Canadian pharmacy. Send me the names and I can see what kind of help is out there.

Ben Washington · Answer

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? Since original medicare only covers prescription medication taken in doctors office; Supplemental plan want help reduce your cost for specialty medication ,but you request Formulary Exception:  A request to get a specific medication at a lower cost or tier or Tiering Exception a request to have a drug placed in a lower tier, which would result in a lower copay. or drug manufacturer for help or SSA for special help or LIS low income subsidy which help with drug cost.

Answered by Ben Washington on May 13, 2025

Broker Licensed in IL, FL, MN, SC, TX & WI

Answered by Ben Washington Medicare Insurance Agent

Michael Denniston · Answer

There many ways to address this issue. Some options are laid out in the Medicare and you booklet for 2025. There is LIS and Extra help available to many that qualify. You can appeal for tier exception if it is a drug you have to have. There are manufacturer programs to save $ and many other options too. Call us today with any of these type scenarios, we can help.

Answered by Michael Denniston on June 1, 2025

Agent Licensed in FL, AL, AR & 11 other states

Answered by Michael Denniston Medicare Insurance Agent

Laura Shipman · Answer

There are some options available for those folks who are prescribed specialty drugs.
One option is to check with your doctor to find out are there other options available that may be effective but cost less money.  Another option is to check whether there is a Spap available in your state that may cover that medication.  There are also patient assistant programs with some manufacturers that may help pay some or all of the specialty drug.

Sherry Rose · Answer

Have you applied for Extra Help on your Prescription cost?  Also, you can check your prescription plan during the Annual Open Enrollment each year that runs from Oct 15th to Dec 7th of every year.

Gina Giambri · Answer

Are you utilizing the Medicare payment plan with your current carrier? 
And if your drugs are not covered you may be in the wrong plan.

Steven Bleicher · Answer

You have to explore how you can save by reaching out to the drug's manufacturer online for a possible subsidy as well as checking the US and Canadian discount websites like the Canadian Medstore, costplusdrugs.com, GoodRx.com, pharmacychecker.com, simplecare.com, and many more! You have the 2 options of using your Part D plan OR the above suggestions; but not both for the same Rx, though. There also are foundations to apply to and they can be Googled.

Answered by Steven Bleicher on May 29, 2025

Broker Licensed in AZ

Answered by Steven Bleicher Medicare Insurance Agent

Norman Smith · Answer

The G Supplement is the best you can get, glad to see you were wise enough to invest in yourself and your health!
There are a couple of things currently that may help depending on the medication:
1) - Depending on the medication and frequency, if you can have it administered at your D.O.’s office it would be billed under your Part B, and not your Part D. Then any excess would be paid by your Supplement.
2) - if it is a high tier or specialty drug, then you could go to the manufacturer and apply for a special discount directly from them and it may even be free!
3) - Check other pharmacy’s!! The pricing differences between pharmacies can sometimes be quite substantial. Have your agent, or you yourself can look at Medicare.gov and find the least expensive place for that prescription.
4) - The current administration is looking to assure that Americans pay no more than any other country for our needed drugs, and depending on how it happens could save 30-80% on current prices!
Good luck!

Andrew Zurbuch, MBA · Answer

It depends where it is dispensed. If you get it at a local Pharmcy or mail order Pharmacy, then please contact your Insurance Company on the Part D Policy & ask the representative of the Insurance Company for a Tier Exception. They have so many specific hours to respond to you. 
If it is administered by your Doctor's Office, then it falls under Medicare Part B. Thank you. 

Andrew J. Zurbuch, MBA
Licensed Broker

Tammy Stoner · Answer

Enroll in the prescription payment plan through your RX plan to budget the costs of your medicine.
You will be capped at $2000 per year and can enroll at any time. 

You may have an option to submit to the manufacturer of the drug for discounts or grants. Often times this will be based off income or assets.

Tammie Rutledge · Answer

The Good new is that the max out of pocket for Part D is now $2,000.00.  Once you have hit the max out of pocket, your Specialty Medications will be covered for the remainder of the year.

Carol Thompson · Answer

One option would be to contact the pharmaceutical company who manufactures the medications for any grants or discount programs. 

The client could look into State Pharmaceutical programs as well as discounts with prescription drug cards such as Good Rx & Clever Rx. 

As an agent I can assist a client to see if they may qualify for Medicare Savings Programs.

Andrew Kramer · Answer

Your Rx costs cannot exceed $2,000 annually, according to the new Part D rules from the IRA (Inflation Reduction Act) from 2024. If that is still unaffordable, you can contact the manufacturer of the Rx on their website and find a form for reduction of cost, based on your income. You may also qualify for the LIS, based on your income (Low Income Subsidy). Call Medicare or the SSA to see if you may qualify.

Answered by Andrew Kramer on May 19, 2025

Agent Licensed in FL

Answered by Andrew Kramer Medicare Insurance Agent

Glenn Alterman · Answer

The max OOP is $2000 plus your deductible for 2025 so if you are close to this, you will be in good shape

If you want me to help you so you don’t have to pay anything or pay less, I can look at the RX and see if there is a free or discounted option for you

Ross Landon · Answer

You might ask your doctor if he or she is aware of some manufacture discounts.

 With real expensive medication’s, often times, the manufacturer will have samples that you can use to help out with those high drug specialty costs!

Tony Hardwick · Answer

In this situation, you may be able to save quite a bit monthly by enrolling in an MAPD plan. A majority of the plans have a $0 monthly premium and include prescription drug coverage. This will put you in a position to discontinue both the Plan G and Part D premium. This would help reduce any potential financial burden. The specialty drugs would be capped at a certain amount depending on the tier it's listed.

Answered by Tony Hardwick on April 28, 2025

Agent Licensed in GA, AZ, CA & 15 other states

Answered by Tony Hardwick Medicare Insurance Agent

Karen Ansell · Answer

You have several options to help with medication costs.

1. Look into Low Income Subsidy which is through your state. This benefit can assist you with your Part D premium and costs of your medications. You can apply through www.Medicare.gov or www.ssa.gov. You must meet certain income and resource limits.
2. I also recommend contacting the pharmaceutical company who makes the medication.
They may have programs available to help with the medication costs and are easier to qualify for. 
3. Consider an alternative medication with lower copays.
4. The 2025 Part D prescription plans have a maximum of $2000.00 annually out of pocket for all your medications together.

Eizel Mere · Answer

One a year ypu should take the time to sit down with your agent and review Part D plan. Formulary change every year and that may affect what you pay. This year we have the firat maximum in payment, $2000, but this only counts with medications on formulary. For the rest of the year for medications not in formulary can use prescription discounts like AARP or Canadian pharmacy.

Answered by Eizel Mere on May 26, 2025

Broker Licensed in FL

Answered by Eizel Mere Medicare Insurance Agent

Jack Mayer · Answer

Contact us and we can shop out your PDP plan and find the best offer on the right formulary for your meds or compare what you have to a MAPD

Ellen Diehl · Answer

Is this an infusion medication?  If it is administered in office it might be covered under Part B.  You need a Broker like me who is smart and can help you.

Robert Rowe · Answer

There’s a couple options for you. The first option is that you may have to contact your doctor and ask that the drug be added to your drug formulary or contact your PDP provider and ask that the drug be covered under the plan. The other option is that you may be dealing with a chronic condition that would require its own C-SNP or Chronic Special Needs Plan. These plans have an extra tier of drug coverage for those using expensive drugs for Heart Failure, Diabetes and End Stage Renal Disease.

Answered by Robert Rowe on May 17, 2025

Broker Licensed in MI

Answered by Robert Rowe Medicare Insurance Agent

Donnie Vermillion · Answer

Talk with your doctor about alternate dosages or generic drug options. 

Talk with your pharmacy about discount programs.

You may qualify for "extra help " if your income is below a certain level. 

You can also request a tier exception on your medications, this requires doctor support.

Mike Sosso · Answer

It is important that you shop your Part D prescription coverage every year. In 2024 all the Part D carriers revised formularies because Congress mandated that in 2025 seniors would not have to pay more than $2000 per year for prescription drugs. For this reason, many of the prescription plans revisions excluded some of the higher cost medications in thier formularies.  If you are in a situation where your plan has excluded a medication you are taking, contact your drug Medicare (800) 633-4227 and your drug plan to ask for an exception. When you talk to Medicare, you can also see if you qualify for special financial help to pay for your medications.

Then next year during the annual enrollment period, October 15 through December 7th make sure you shop your Part D prescription coverage and include all your medications in the formulary search to find the most affordable coverage.

Maci Mishler · Answer

The good news is the max out-of-pocket costs was lowered in 2025, but there are still very expensive medications out there. If this is a compound med there is not a ton we can do, but if it's just an expensive name-brand look into manufacturers programs or grants.

Answered by Maci Mishler on June 9, 2025

Broker Licensed in NE, AR, KS & MO, ND, OK & TX

Answered by Maci Mishler Medicare Insurance Agent

Michael Hixson · Answer

Original Medicare and your Medigap Plan G only cover cost associated with your Part A and Part B coverage, Hospital and Doctor coverage. Your medications are covered by Medicare Part D and you should shop Part D coverage each year during Annual Enrollment Period, October 15 - December 7, because each year the Premiums, Plan Formularies and Copays change.

Answered by Michael Hixson on April 23, 2025

Broker Licensed in OK, AR & TX

Answered by Michael Hixson Medicare Insurance Agent

Shannon Brenneke · Answer

You could add on a Hospital Indemnity policy which will assist with paying you directly for some of the out of pocket expenses you incur. There are many options you can add on such as Cancer, Accident, Critical Care, etc for typically a low cost.

Answered by Shannon Brenneke on June 2, 2025

Agent Licensed in MO

Answered by Shannon Brenneke Medicare Insurance Agent

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?

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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?

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