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

Clarence &quot;Mark&quot; Christiansen · Accepted 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

Charise Karjala · 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).

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.

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

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.

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

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.

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

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?

Agents: Share Your Expertise

Related Questions

Agent Locator

Medicare Agents Hub
A non-government resource website

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?

Agents: Share Your Expertise

Related Questions

Agent Locator

Medicare Agents HubA non-government resource website

Medicare Agents Hub
A non-government resource website