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.

Gary Church · Answer

To answer your question, it's not your health plan with Medicare or your supplement. The problem is your drug plan. A few things you can look into are reaching out to your drug plan to see if they can help change the tier level, reaching out to the manufacturer to see what options are available to lower the cost, and talking to your doctor to see if there's an alternative or a generic. I would recommend working with a licensed Medicare agent who can review your current drug plan when AEP comes in October to see if there are changes you should make.

Answered by Gary Church on February 23, 2026

Broker Licensed in Ca, AZ, NV & TX

Answered by Gary Church Medicare Insurance Agent

Mike Alexander · Answer

You can ask for an appeal or exception for that med
In some cases ask your doctor if there is atrail program fir that med ,

Mark Bilgere · Answer

The first place to look is the Part D plans available in your area. Different plans may have different co-pays for the same medications. You can also look into programs with the drug manufacturer. They often have plans to help people with the cost of medications. You can look into drug discount programs like GoodRX. Finally you can speak to your doctor to see if they can provide samples or suggest an alternative medication.

Answered by Mark Bilgere on November 29, 2025

Broker Licensed in TX, AR, IN & LA, MN, NE & OK

Answered by Mark Bilgere 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!

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

Mark Maliwauki · Answer

All Big Pharma companies have programs where they actually give you your medication for free. It is a year to year type of thing but it is definitely worth checking out. Outside of that,  you want to make sure that your pharmacy choice is always in network and more importantly a preferred pharmacy in their network to ensure you are getting the lowest price on your meds. 

Lastly, depending on which medication it is, every year Medicare and Medicaid services (CMS) will add 15+ Rx to a list of capped pricing. This is what they did with insulin last year.

Steven Graves · Answer

You're in a common (and frustrating) situation—you're doing everything right with Original Medicare, Medigap Plan G, and Part D, but specialty drug costs can still break the bank. Here's what you need to know—and what you can do:

Why Specialty Drugs Are So Expensive (Even with Part D)
Part D plans often place specialty medications on the highest tier (Tier 4 or 5), which means:

You may pay 25% or more of the drug cost, even after meeting your deductible.

Some medications can cost thousands per month, especially for conditions like cancer, MS, or rheumatoid arthritis.

And unlike Part B, which often has 80% coverage for infused drugs, Part D covers self-administered medications with less protection.

 Options to Lower Specialty Drug Costs
1. Apply for the Extra Help (Low-Income Subsidy) Program
If your income and resources qualify, this program can dramatically reduce premiums, deductibles, and copays—even for specialty drugs.

You don’t need to be on Medicaid to qualify

Many seniors are eligible and don’t realize it

2. Switch to a Part D Plan with Better Drug Coverage
Plans vary widely in:

What drugs are covered

Tier placement

Copay structure

 Use the Medicare Plan Finder to compare costs for your exact medication each year during Open Enrollment (Oct 15–Dec 7)

3. Apply for Manufacturer Assistance or Copay Cards
Some drug companies offer patient assistance programs or copay support cards, even for people on Medicare. These aren’t always advertised but can make a big difference.

Search: “[Your drug name] + Medicare assistance program”

4. Check for Foundation Grants
Organizations like:

PAN Foundation, Good Days, Health Well Foundation or Patient Advocate Foundation

…offer grants to help cover specialty drug costs for people with specific diagnoses—even those on Medicare.

5. Ask Your Doctor if the Drug Can Be Administered Under Part B
Some specialty drugs can be administered by a provider (e.g., injections or infusions), which may shift coverage to Me

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

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.

Kerwyn Jones · Answer

Compare your current Prescription Drug Plan to others on the market. Is an SEP(Special Election Period) exist for you, then consider changing to better plan. You can also call the Manufacturer of your pricier drugs and ask for any assistance program they have available to reduce the cost of the drugs

Answered by Kerwyn Jones on October 22, 2025

Broker Licensed in FL, AL, AZ & 21 other states

Answered by Kerwyn Jones 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.

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.

Andrew Firmin · Answer

All right, you have Medicare. You have a supplemental Plan G and a Part D prescription drug plan, but you're still facing some very expensive prescription drug co-pays. When you go to the pharmacy, it's important to review your coverage and your plan annually because every insurance company has a different plan formulary, a list of covered prescriptions.

Now, if you're continuing to pay a lot of money for your prescriptions, there may be another plan out there that has a more favorable plan formulary or coverage for you. Not all prescriptions are covered by Medicare and Medicare Part D. If your prescription is not covered, there are a number of solutions for you.

First, you can look towards a grant or a foundation to provide you with financial assistance. You can look to Medicare's low-income subsidy or Medicaid, or the Medicare savings program. You can also look towards services, discount coupon services such as GoodRx. And finally, you can look towards a Canadian pharmacy. Perhaps the Canadian Med Store or Maple Leaf Funds are both reputable Canadian pharmacies that you may search.

I hope that helps. Until next time, be healthy and be well.

Sandra Teel · Answer

Standalone prescription drug plans are often more expensive on specialty drugs.  
1) You can ask your doctor to petition the prescription drug company and ask for a "tier reduction". If the insurance company agrees, it can help cover your specialty drug at a lower cost.
2) You can also ask your doctor to help you reach out to the manufacturer of the drug to see if you qualify for a discounted price from the manufacturer.

3) Lastly, if the prescription drug company covers your drug, then Medicare will "Cap" your out of pocket costs for ALL your prescriptions at $2,100 for the 2026 year.  This means once you have paid $2,100 for your covered prescriptions, ALL your prescriptions will go to a zero cost for the rest of the year.

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.

Kate Spilsbury · Answer

That’s a tough spot to be in, and it’s more common than most people realize. Even with great coverage like Plan G, specialty medications can be expensive. You may qualify for Extra Help (Low-Income Subsidy) or manufacturer assistance programs that can dramatically reduce your costs. My team can review your medications, income, and available programs to see what savings might apply—we do this at no cost to you.

Answered by Kate Spilsbury on October 20, 2025

Broker Licensed in FL, AZ, CA & 7 other states

Answered by Kate Spilsbury Medicare Insurance Agent

Cody Hebden, MBA, CLU, FLMI · Answer

Great Question! There's really two answers here, so it depends on if your specialty medication is covered by Part B, or if it falls under Part D prescription drug coverage. Based on you having high costs, I am assuming your drug does not fall under Part B. As such, since every Part D plan has a "formulary" (list of covered drugs), by law, they must provide drugs that provide care to nearly every type of illness or issue. However, that doesn't mean your drug is on the formulary. And if it is not, you're not covered by insurance for the cost. You should work with your doctor to see if there is another acceptable drug that will have the same therapeutic benefits that is on your plans formulary. Otherwise, you can request an appeal from Medicare, and with your doctor's assistance, you can request a formulary exception - to get your Part D plan to cover the drug. If the drug is still too expensive, you should see if you qualify for any "extra help", by going to Medicare.gov for more information.

Answered by Cody Hebden, MBA, CLU, FLMI on August 13, 2025

Broker Licensed in NC & SC

Answered by Cody Hebden, MBA, CLU, FLMI Medicare Insurance Agent

Bill Green · Answer

Having Plan G, Part D, and some expensive medication costs is rather not ordinary. When it comes to medications, it's a matter of where the medication is filled. If you're getting it from a pharmacy, Walgreens, CVS, your local grocery store, wherever it is, it would fall under your Part D drug plan, which this year, as long as the medicine is on the formulary, has a max out-of-pocket of $2,000. However, if, say, your medication is not on the formulary and you're paying full retail costs for it, then it would not count towards the $2,000 max. If it's not on formulary, that's when people want to work with their agent to try to ask for it to be added to a formulary. I won't say it's a 100% success rate, but I've seen a vast majority get approved. The other thought or option is if it's administered in a medical setting, like a doctor's office, hospital, or cancer treatment center, even if it's not a cancer medication, it should be billed under Part D. This would mean once you measure a doctor for medical care, you're covering anything else for it. It sounds like there's something either funky going on with the billing or maybe if it's through your Part D, it's just not on the formulary. Either way, this doesn't sound normal. I would definitely reach out to the agent, and they'll just set you up on this plan and ask them to help out.

Bubi Gorgevich · Answer

You should review your part D considering the formulary list of your drugs with different options. Effective way to lowering your cost will be contacting the manufactorer of your specialty drug and ask for their assistance in cost sharing.

Answered by Bubi Gorgevich on October 1, 2025

Broker Licensed in SC, AZ, CA & 7 other states

Answered by Bubi Gorgevich 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.

Oscar Chavez · Answer

I would advise you to ask your pharmacist if they work with a discount plan like GoodRx or SingleCare to shop for a price.

Angela Ellington · Answer

There is now a $2000 Catastrophic limit on Part D costs, so once you hit that threshold, you'll be done paying for RX copays on formulary drugs for the remainder of the year. You can also enroll in a payment plan to spread those costs over the course of the remaining months of the year to avoid paying a high deductible in one payment. You can also compare pricing at the Canadian Med Store if they offer your drug. If you have low income, you may qualify for Extra Help from Social Security.

Answered by Angela Ellington on June 30, 2025

Agent Licensed in CA, AZ, FL & 9 other states

Answered by Angela Ellington Medicare Insurance Agent

Martin Meyer · Answer

I would definitely shop prescription drug plan options during the annual election period, but a specialty drug will be expensive on all plans. Your best bet would be to apply for a patient assistance program through the manufacturer or a third party assistance program. Google the name of the drug, followed by patient assistance program and see what’s available. If approved, it will be covered for next to nothing, and it completely stays off of the insurance. Good luck!

Answered by Martin Meyer on October 6, 2025

Broker Licensed in IL, AL, AR & 18 other states

Answered by Martin Meyer Medicare Insurance Agent

Misty Scaggs · Answer

As of 2025 Medicare offers a Prescription Payment Plan which would allow you to spread out your costs throughout the year. You could also explore manufacturer assistance programs, checking for lower-cost generic or alternative drugs, or using a mail-order pharmacy.

Answered by Misty Scaggs on July 15, 2025

Broker Licensed in MO, FL & IL

Answered by Misty Scaggs Medicare Insurance Agent

Gabriel Reinhardt · Answer

Even though Part D prescription drug plans are regulated, the price one pays for those drugs can vary greatly based on many factors. Let's explore two of the main ways that prescriptions can cost more than have to.
CMS (Centers for Medicare and Medicaid Services) requires that all drug plans have at least two drugs in each therapeutic class, meaning you will have at least two drugs to choose from for your ailment. However, CMS does not tell the drug plans which drugs they have to cover. So, if a plan does not cover a particular specialty medication (or any medication), the full cost of that drug will be on the Medicare recipient with no cost sharing from the drug plan. In this case, the drug is considered "not covered" by the drug plan. 
Another reason why a specialty medication (or any medication) cost may be high is if the drug was covered by the plan, but the Medicare recipient did not use an in-network pharmacy (or went to an in-network pharmacy but not preferred pharmacy). The same drug could be more expensive based solely on the pharmacy used to fill the prescription. 
It's important to not only check that all prescriptions are covered by a plan, but to check pricing across many plans and across many pharmacies, to ensure you are getting your prescriptions at the lowest possible cost. 
There are other factors that may play a part such as premiums, deductibles, and drug tiers. At Strong River Insurance, it is a standard practice to compare all drug plans available in your zip code, based on your prescriptions, and to find the lowest total annual cost at an acceptable pharmacy within a radius of your home.

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, GoodRx, pharmacychecker, simplecare, and many more! You have the 2 options of using your Part D plan OR the above suggestions: but not 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

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

Steve Houchens · Answer

Some options would be to see if your doctor could prescribe a medication that would work for you issues that have a cheaper co-pay , shop to see if there is a plan that covers your medications better because plan formularies do differ. You could also see if you qualify for extra help getting those medications covered

Answered by Steve Houchens on July 19, 2025

Agent Licensed in KY & TN

Answered by Steve Houchens Medicare Insurance Agent

Jim Tretola · Answer

See if you can apply for an exception, as well as if there are alternative medications. Manufacturers coupons can also help.
Keep in mind yearly out of pocket for Medications will be capped at $2,100.

Michael Pyers · Answer

Your plan D now includes a $2000 maximum out of pocket per year.  That was from the inflation reduction act.

Priscilla Ramos · Answer

To lower high specialty drug costs with Original Medicare, Medigap G, and Part D:

Compare Part D plans for better coverage
Apply for Extra Help to reduce copays
Check state or manufacturer assistance programs
Ask your doctor about alternatives or formulary exceptions

Walt Smith · Answer

You should ask a qualified program to review all Medicare part D plans in your area. The plans do very greatly in what they cover. Make sure you’re in the lowest cost plan for your specific medication. Beyond that on specialty modifications that are high cost sometimes to manufacture or a foundation associated with will provide economic assistance. Several of my clients have been successful in this regard

Answered by Walt Smith on June 16, 2025

Agent Licensed in NJ, NY, PA & VA

Answered by Walt Smith Medicare Insurance Agent

Steven A James, MBA · Answer

Generally, I advise that if you have numerous medical service needs, the Medicare Supplement G will ensure that your medical costs are covered and at a known cost; typically, simply the cost of your monthly premiums less the Medicare Part B annual deductible will increase from $257 this year to $288 in 2026.

However, Medicare Part D will have a $615 annual deductible, so depending on your plan, some or all may be mitigated.  Typically, separate standalone prescription drug plans (PDP) will require payment of this deductible.  If you consider a Medicare Advantage Plan (MAPD), you'd save paying the monthly premium of your Med Supp while also having a drug plan included.  For some, this could be an annual savings of =/- $4K alone.

Keep in mind that MAPD plans are only available in certain service areas/counties.  So even if this is the most desired/appropriate option, it may not be available.

The next consideration would be if your drug plan requires copays or coinsurance.  Copays will cap your out-of-pocket cost per medication where coinsurance would require more.  However, for 2021, the annual cap for your out-of-pocket exposure is $2,100.

Steven James
Contact me.

Mal Varlack · Answer

Manufacturers may offer a discount program. Also each state has a state pharmaceutical assistance program that you can contact.

Valerie Schurman · Answer

I would recommend you talk with an agent about an advantage plan that includes a part d plan

thanks

Jason Vallejos · Answer

Part D stand alone plans are having difficulty with managing prescription costs so they are sharing that with the consumers. Currently, Medicare Advantage Plans (Part C) include Part D as well and have typically richer prescription plan benefits. You may want to consider a Medicare Advantage Plan, if you are willing to work with a limited network of physicians.

Answered by Jason Vallejos on October 20, 2025

Broker Licensed in CA, AZ, CO & 17 other states

Answered by Jason Vallejos Medicare Insurance Agent

Sagrario &quot;Sage&quot; Dyer · Answer

For many on a stand alone Part D, specialty medications, or Tier 4 and 5 drugs, are being charged as a co-insurance, or a percentage of the price, which can be between 30% and 50% of the actual price.  If you are paying a higher price, it's a good idea to ask a local agent to review your Part D plan and see if the plan is even covering your medications at all.  You can also ask your pharmacy or call the plan directly to ask about the cost.  

If the plan is not covering your specialty medication, remember that you can should be asking your a doctor to ask the plan for an exception to include it into the formulary.  The plan must respond with 72 hours of the request. You may have to go through Step Therapy, prior authorizations or quantity limits, but the amount you will pay will go toward a $0 co-pay in the long run.  

If Medicare approves of the drug being a covered medication, than your Part D has to cover it.  This means that what you pay, the plan pays and the manufacture goes toward your TrooP of $2,100 initial coverage amount.  One you reach the $2,100, you pay $0 for the rest of the year.  The beginning of the year is the most expense because you are paying your deductible first, but after that, if your medication is costing nearly $1,000 a month, you should be reaching your maximum out of pocket by mid-March.  You can also ask the plan to put you on a payment plan, which will spread the cost out evenly through out the year.  

Always remember, ask a local agent for help.  Great agents provide these reviews at not cost to you, but they are also not getting paid by the plan to help, since many  so be plans have de-commissioned their Part D plans, so be prepared with your drug list and take note of the suggestions.

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.

Cindy Clonts · Answer

You can try to get a formulary exception, check GoodRX or apply for a Grant.  There are also a lot of discount programs and websites for needy individuals.

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.

Marva Becker · Answer

In some cases Drug manufacture's help pay for drugs under special programs. Check with your doctor to make sure you are taking advantage of generic brands and always check with your Broker to discuss all of your options

Answered by Marva Becker on December 8, 2025

Broker Licensed in WI, IA, MA & MN

Answered by Marva Becker Medicare Insurance Agent

Bill Brann · Answer

A lot of people are shocked to learn that even with Original Medicare, a Medicare Supplement Plan G, and a Part D drug plan, specialty medications can still be very expensive. Unfortunately, Medigap plans like Plan G do not help cover your Part D prescription drug costs.

The good news is you still have options.

First, it’s very important to review your Part D drug plan every year. Not all plans cover specialty medications the same way. Sometimes simply changing your Part D plan during Annual Enrollment can save thousands of dollars a year depending on your medication.

You should also look into the Medicare Extra Help program. Many seniors qualify and don’t even realize it. This program can help reduce prescription drug costs significantly.

Another option is checking directly with the drug manufacturer. While Medicare recipients usually can’t use regular copay coupons, many pharmaceutical companies have patient assistance programs for people taking high-cost specialty medications.

It’s also worth asking your doctor if there are:

* lower-cost alternatives,
* biosimilars,
* or different treatment options
  that may still work well for your condition.

Make sure you are using the correct preferred or specialty pharmacy required by your Part D plan. This alone can sometimes lower your costs considerably.

Beginning in 2025, Medicare Part D also includes a yearly out-of-pocket maximum for covered medications, which should help protect people from unlimited prescription drug spending.

Every situation is different, which is why I always recommend having someone review your exact prescriptions and Part D coverage every year.

Dixie Obbink · Answer

Your options really depend on what medication you are taking. There could possibly be some assistance programs available but that depends on some factors. Depending on where you are located there may be a specialty pharmacy in your area and they may have a program that could be of assistance. If your specialty medication is not on the formulary of your Part D plan, you could ask your doctor to request a formulary exception.

Answered by Dixie Obbink on April 20, 2026

Broker Licensed in SD, AZ, IA, MN & NE

Answered by Dixie Obbink Medicare Insurance Agent

William Page · Answer

You should ask your physician, pharmacy and the part D provider if there are any other options such as alternative drugs that may work just as well. You could also contact Good RX and your State Pharmaceutical Association for discount options and programs that may be available. In 2025 you will have a maximum out of pocket for prescription drugs that are included in the part D formulary of $2000 that can be divided by 12 into monthly payments.

Answered by William Page on October 5, 2025

Agent Licensed in NC & SC

Answered by William Page Medicare Insurance Agent

Hunter Oswald · Answer

Typically, we can check a few different routes. 1. If not on the companies formulary we can check with the provider on a formulary exemption. 2. You may qualify for income driven programs through the state that could help cap the costs of your Part D meds. 3. We can check with an external provider such as the Canadian MedStore to see if we can find the medication at a cheaper rate.

Answered by Hunter Oswald on December 1, 2025

Broker Licensed in GA, AL, FL & 8 other states

Answered by Hunter Oswald Medicare Insurance Agent

Vachik Chakhbazian · Answer

consider exploring these options: switching to a different Part D plan, seeking manufacturer assistance programs, or investigating state-run programs. If you have limited income and resources, Extra Help or Medicaid may also be available to further reduce costs.

Answered by Vachik Chakhbazian on June 14, 2025

Agent Licensed in CA, AL, AR & 22 other states

Answered by Vachik Chakhbazian Medicare Insurance Agent

Mary Brown · Answer

If your specialty drug is still expensive, you may have options: check whether you qualify for Extra Help (LIS), review whether a different Part D plan covers your medication at a lower cost, ask about lower-cost alternatives or manufacturer/copay assistance, and see if the Medicare Prescription Payment Plan can spread costs out over time. Also, Medicare Part D now has an annual out-of-pocket cap for covered drugs, which can help limit expenses.

Answered by Mary Brown on May 25, 2026

Broker Licensed in NJ, DE, FL & NC, OH, PA & TX

Answered by Mary Brown Medicare Insurance Agent

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

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.

Marcie Barnes · Answer

The Medicare Prescription Payment Plan (PPP) is a new, voluntary option for Part D members to spread out their out-of-pocket drug costs into monthly installments throughout the year, instead of paying large amounts at the pharmacy, helping manage budgets but not lowering total drug costs. You enroll through your Part D plan, and it's especially helpful for those with high-cost drugs early in the year, allowing for $0 payments at the pharmacy counter once enrolled. 
How it Works
Spreads Costs: You pay your share of drug costs monthly, not all at once when you fill prescriptions. 
No Added Cost: It's free to join and doesn't save you money, just changes when you pay. 
Capped Payments: Payments stop once you hit the annual Part D out-of-pocket maximum (e.g., $2,100 in 2026). 
Monthly Bills: Your bill is calculated based on what you would have paid, spread over the remaining months.

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

Dean Chiapetto · Answer

Specialty medications can be expensive. Unfortunately the companies have stopped using agents and expect you to self enroll. Find a good local agent who may help. For 2026 there is a cap of $2100. You can spread payments over 12 months. Always question your Dr. The drug manufacturer may have palns to help.

Answered by Dean Chiapetto on November 1, 2025

Broker Licensed in VA, MD, NC, TN & WV

Answered by Dean Chiapetto Medicare Insurance Agent

Carol Conner · Answer

Maybe you should look at other options and see if the Medicare advantage would be a better fit for you. I would suggest you contact a licensed insurance agent and let them help you with that.

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

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

Mel Stevens · Answer

Paying higher costs with tier 3,4 and 5 medications is never fun. One very good option is to contact the manufacturer directly. Often, they will offer the medication at a discounted price or sometimes even something like 6 months for free.

Answered by Mel Stevens on July 2, 2025

Broker Licensed in AZ

Answered by Mel Stevens Medicare Insurance Agent

Rich Baker · Answer

Your costs will be capped at $2100 in 2026, but if you have a high monthly cost early in the year you do have an option called the Medicare Prescription Payment Plan (MP3). The MP3 doesn’t reduce your drug cost, but it spreads it out. 

For example, if you have a drug that will cause you to hit the $2100 limit in the first couple of months of the year, if you sign up at the start of the year, you would pay $175 per month through the end of the year. You’re still paying $2100, but not all at once. Obviously the earlier the better for this idea. Reach out to your plan’s customer care number for more information.

You can press your doctor for any alternative meds (generics or biosimilars) that are lower cost but still treat the same conditions. You can also ask about free samples, or if a higher dosage can be prescribed which you then split in half each day.

If you have limited income, you have some additional options; 

1. Extra Help (details at https://www.ssa.gov/medicare/part-d-extra-help). Depending on your income, you can reduce or eliminate your copays and deductibles if you qualify. 

2. Manufacturer assistance. Needymeds.org and RxAssist.org have directories you can use to find assistance programs. These are also normally income or needs based.

3. Many states have a State Pharmaceutical Assistance Program (SPAP) which can help you. If you qualify you may even get a Special Election Period to change your Part D plan too.

You can also look at discount card programs like GoodRX or RxSaver. 

There are alternative pharmacies like CostCo, Mark Cuban’s Cost Plus Drugs, and I think even Amazon is developing an alternative pharmacy.

Lastly, you should always shop for coverage during annual enrollment. You may find a plan with a lower deductible, or a flat Tier 3 copay vs a percentage coinsurance. Your agent can help you with that process, or you can go to medicare.gov or the carrier’s website to compare costs.

Adam Ernst · Answer

If your Part D plan does not cover any of your medications, you may want to seek a better plan or look at the local pharmacy to see if they have their own discount plan. You can also ask your doctor if there are generics that work just as well for a lower price. You can also look into mail order pharmacies as they help you save money, as well.

Answered by Adam Ernst on December 11, 2025

Agent Licensed in NC, SC & TN

Answered by Adam Ernst Medicare Insurance Agent

Julie Thompson · Answer

Your best options would be to consult an agent and give them a list of ALL your medications, so they can compare which stand alone Prescription Drug plan would be best for you. You only have until March 31st to make a change without a qualifying special enrollment event.

Answered by Julie Thompson on February 9, 2026

Agent Licensed in CA, AZ, KY, NV & TN

Answered by Julie Thompson Medicare Insurance Agent

Cheryl Lyons · Answer

Even with Original Medicare, a Medigap Plan G, and a Part D plan, specialty medications can still be costly because:

Medigap doesn’t cover prescription drug costs—it only helps with Parts A and B cost-sharing.

Part D plans still require deductibles, coinsurance, and cost-sharing, especially on specialty tier drugs, and most of that you pay until you hit the catastrophic/cap limit.

Here are options you can consider:

🧾 1. See if You Qualify for Part D “Extra Help”

Medicare’s Extra Help (also known as the Low-Income Subsidy) reduces or eliminates Part D costs — including premiums, deductibles, and coinsurance — if your income and assets are below certain limits.

Benefits may include:

$0 Part D premium and deductible

Very low copays ($5.10/generic, ~$12.65/brand in 2026)

No late-enrollment penalty

Lower out-of-pocket cost overall

How to apply:
You can apply through the Social Security Administration or your local State Health Insurance Assistance Program (SHIP) for free help completing the application.

🧑‍⚕️ 2. Ask About a Different Part D Plan Next Enrollment Period

Not all Part D plans cover specialty drugs the same way — formularies and tiers vary.

Some plans put a drug in a less expensive tier or negotiate better pricing.

Switching plans during Annual Enrollment (Oct 15–Dec 7) or via special enrollments (e.g., if you qualify for Extra Help) might reduce your costs.

👉 Use the Medicare Plan Finder online or get help from a broker/SHIP counselor to compare how your specialty drug is covered in different Part D plans.

💳 3. Explore Patient Assistance / Non-Profit Aid Programs

There are nonprofit and advocacy organizations that help pay drug costs when insurance still leaves high out-of-pocket costs, including specialty medications. These can help with copays, coinsurance, and other related expenses:

Examples include:

PAN Foundation – financial assistance for out-of-pocket costs

Patient Advocate Foundation (PAF) Co-Pay Relief

The Assistance Fund (

Brent Mowery · Answer

You can research your medication online to see if there are cheaper options. Also, you could contact the manufacturer to see if they offer any "patient assistance" programs.

Toni Chavez · Answer

During AEP looking at another Part D plan that may have a better formulary and tier pricing.  Find a local broker that can compare plans and costs based on your drugs.

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

Jami Mead · Answer

Depending on your area and income, there are options Available to You For assistance with your high cost specialty medication. I have had clients reach out to the manufacturers of the companies to help get lower costs on their medications. During an open enrollment period you can also take a look at other part D plans review what you have and what medications you take to see if the cost would be different on a different plan. They do change every year.

Answered by Jami Mead on July 7, 2025

Broker Licensed in OH, FL, GA & 11 other states

Answered by Jami Mead Medicare Insurance Agent

Adam Paul · Answer

Medicare Advantage Prescription Drug (MAPD) plans are a great option because they include hospital, medical, prescription drug, and other ancillary benefits at no additional cost.

Natalee Nimmo · Answer

I would talk to a broker, which is someone that’s licensed with all the carriers. It could be that you just need to change your part D plan. A broker can also look at different things like your income level and gauge whether or not you would qualify for a program called extra help. This program helps to lower prescription costs and is offered through Social Security. If those two options don’t work then the third option would be to look if there is a manufacturers coupon or a pharmaceutical assistance program that would help lower the cost. Lastly, would be to contact your current part D program and ask them for a formulary exception or a tear change exception, depending on your situation.

Answered by Natalee Nimmo on May 18, 2026

Broker Licensed in SC, FL, GA & KY, MO, NC & TX

Answered by Natalee Nimmo Medicare Insurance Agent

Earl Beck · Answer

You coukd not to change to a Medicare Advantage plan, that has Rx Drug coverage. It depends on what "Tier" level your specialty medication is in or falls under. Normally it is Tier 5, which means a higher cost depending on the medication.

Answered by Earl Beck on November 15, 2025

Agent Licensed in PA

Answered by Earl Beck Medicare Insurance Agent

Ashley King · Answer

There are a few options you can explore to help dealing with those high costs. You can apply for Extra Help which is a federal subsidy that can lower drug costs along with exploring other Part D plans that may be available offering to cover more of those drug costs. Your state may also have assistance programs you can apply for along with checking with the drug manufacture to see if they offer any discount programs. Lastly, you could explore other options such as Medicare Advantage plans that include prescription drug coverage.

Answered by Ashley King on October 28, 2025

Broker Licensed in MD, AL, AR & 9 other states

Answered by Ashley King Medicare Insurance Agent

Shahwali Hotaki · Answer

If your specialty drugs are still expensive, you can apply for Extra Help, use drug assistance programs, check state/Medicaid aid, rely on the new $2,000 Part D cap, or consider Medicare Advantage for better coverage.

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.

Ingrid Kollmann · Answer

First of all, there's an annual cap on prescription drugs of $2,000 after which your prescriptions are fully covered.  Secondly, you can pay your copayments over a period of time so you don't have to come out of pocket for the full amount.

Cynthia Allen · Answer

If you have any high cost specialty drugs you can:  1.  Compare costs with other prescription drug plans, 2.  Enroll in the Medicare Prescription Payment plan, which enables you to spread out the costs of your drugs over the year— keep in mind the out-of-pocket costs for all beneficiaries is now $2000, so if your drugs go beyond that you do not pay.  3.  Apply for Extra Help if you are low-income, 4.  Ask your doctor to see if there is a less expensive generic or brand name drug that you can substitute, 5.  Contact the drug manufacturer to see if they offer their own assistance program to help pay, or see if your state may have programs -State Pharmaceutical Assistance Program.

Sean Macbean · Answer

There are several things you can do to reduce the high costs of prescriptions:

A. Go to your Doctor for Samples. 

B. Use a GoodRx discount card.

C. Apply for Extra Help through Medicare. 

D. Purchase your perceptions from Canada ( 20%) savings on average. 

E. Check out the prescription program of an advantage plan, there are special plans for people with Heart, Diabetes, and Veterans, called SEPs.

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!

Michael Gilman · Answer

Great question — and the good news is there are several programs that may help reduce your specialty medication costs, even with Original Medicare, a Medigap plan, and Part D:

In General:

The $2,100 annual out-of-pocket cap on Part D prescriptions is now in effect — once you hit that amount, your plan covers 100% for the rest of the year.

The Medicare Prescription Payment Plan lets you spread your out-of-pocket drug costs into equal monthly payments — interest-free. Just call your Part D plan to enroll.

Extra Help (Low Income Subsidy) through Social Security can dramatically lower your premiums, deductibles, and copays if you meet income and asset guidelines.

Manufacturer and charitable assistance programs exist for many specialty medications and can help cover remaining costs.

Reviewing your Part D plan each year during Open Enrollment (Oct 15–Dec 7) is important — a different plan may cover your medication at a lower tier or cost.

I'd recommend you sit down and review your specific situation with a qualified agent to help you identify which options apply to you.

Remember in order for a qualified agent to speak in detail with you ... first you will need to fill out a SCOPE form that gives permission to get into the details with you.

Tammam Tayara · Answer

Even with Medicare, Medigap, and Part D, specialty medications can still be very expensive. You may qualify for programs like Extra Help, manufacturer patient assistance, or state pharmaceutical assistance programs that reduce drug costs. It’s also worth reviewing different Part D or Medicare Advantage plans during open enrollment to see if another plan offers better coverage for your specific medication.

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.

Lakisha Bryant · Answer

You may contact the manufacturer for the specialty drug. You can also speak with the doctor who prescribed the medication to you to see if there are any programs to help pay for it. Also, check for any alternative medications.

Martha Lopez-Elkind · Answer

Medicare Advantage also known as Part C, can be a great option because it provides with Medicare-approved plans from a private company that offers an alternative to Original Medicare and Medigap. Medicare Advantage must cover all services covered by traditional Medicare Parts A (Hospital Insurance), and Part B (Medical Insurance) and typically offer extra benefits such as prescription coverage as well as vision and dental coverage.

Glenn Virga · Answer

With some of the changes made to Part D recently this has got better. For 2026 your max out of pocket is $2100 for the year. 
Options to help. Part D now has a prescription payment plan to help spread the cost over the year. Contact your plan for this option.
Another option is to see if your state has any programs. In PA we have the PACE program which many people can qualify for.
Another option is thru the federal government called LIS this is income based also.
As an agent I have helped many people get enrolled into these plans.
Sometimes you can get help right from the manufacture this does entail paperwork that needs filled out every year but it can be a big help.

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.

Mark Summers · Answer

First step (During the Annual Election Period) is to go to www.medicare.gov to see what plans cover your specialty drug. Secondly, I suggest you visit the National Council on Aging website.

Jonathan DuPree · Answer

Make sure you're checking the benefits before you complete a policy, always. It tells you what will be covered and what will not. Also it sounds like you need a Medicare advantage plan D-SNP that will also cover any special conditions you may be facing.

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.

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.

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 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.

Ricky Rash · Answer

Medicare recipients can do a Google search on specialty medications to find various options, such as online Rx coupons, manufacturer coupons and/or financial assistance.  Their physician can also provide samples of a given medication or see if they can qualify for a free trial period.  They can also apply for state pharmaceutical assistance based on income and/or medical condition criteria.

Aimee Butler · Answer

For 2025 with the elimination of the dounut hole, the max you will pay for your medications is $2000 as long as your medication is covered on your current Part D Plan.  You can try contacting the manufacturer of your medication to see if there is a grant or a program directly with them.  You can also contact your doctor to see if they know of any programs for that medication.  If your income meets the requirements you could apply for LIS through the Social Security Administration.  You can also try a program called prescription hope.

April Gruber · Answer

You can review the formulary for your drug plan to determine if an alternative medication is available at a lesser cost. Then discuss that medication with your prescribing physician. You can contact the manufacturer of the medication and see if they offer any coupons or discount programs. You can see if you quality for Extra Help through the Social Security Administration. Due to regulatory changes over the last few years, all Medicare prescription plans are required to offer a new program that assists consumers pay for their prescription drugs. This program is called the Medicare Prescription Payment Plan, or M3P for short. This plan allows you to take the total cost of all your medications and make monthly payments divided across the duration of the current year, up to 12 months if beginning in January. If this program could benefit you or you have a change to your medications mid year, I encourage you to reach out to your insurance carrier and find out what options they offer to support you in your health journey.
Lastly, you can see if a discount drug program like GoodRX could offer you cost savings. The only drawback to programs like GoodRX, will be that nothing you pay out of pocket while using those programs will apply to your maximum out of pocket costs regarding your medications. For some individuals, this is not an issue. However, for some it does make a huge difference in the amount of money they spend on their medications from year to year. 
Regardless, it is always a good idea to meet with a reputable broker to discuss your options.

Isaac Witham · Answer

Copayments for specialty prescriptions can of course become very expensive. Because of this, it is important that you do a comparison to different programs that are available to you as each carrier may cover a prescription very different. There are some programs that you may qualify for(state dependent) that may help lower those cost depending on income. In other situations, there may be patients assistant programs offered by your hospital/provider, that may also be an opportunity to help with those high cost. In that case, it makes sense to check with providers to see if there may be any help available to patients. Lastly, GoodRx may offer high discount codes for that particular prescription. This doesn't always help with every prescription, but may be available for others.

Kerry Clapper · Answer

Specialty medications are typically a Tier 5 medication: therefore more expensive full price and high cost to the Beneficiary. Solutions can be to look for a Part D plan that has a lower coinsurance for Tier 5 medications. There may be some assistance programs those on Medicare can still qualify for through various drug manufactures, Medicare's Extra Help Program and your State Pharmaceutical Assistance Program. 
Medicare also put a cap on how much a Beneficiary can pay for their Part D medications each year and all Part D plans offer the Medicare Prescription Payment Program where you can pay over the year for your medications.