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Thursday, September 12, 2024

Paying for Prescriptions: The Basics

It is almost inevitable that as we age we might need some prescription drugs to assist with medical conditions that are out of our control, or to facilitate our quality of life. How to go about paying for these prescription drugs, however, can be complicated.

Medicaid Part D is prescription drug coverage through Medicare, implemented in 2006 as part of its health insurance for seniors. It is offered through private insurers as a stand-alone plan or as a plan through Medicare Advantage. Each state has multiple Medicare prescription plans and, although having options is nice, choosing the right one for you can be difficult. For example, certain plans may cover more of your prescription drugs, but the premiums may also be much higher, and while other plans may require specific pharmacies to dispense prescriptions, they may not cover all prescription drugs. Before subscribing to a plan, it’s important to do a little research to figure out which one is right for you. Here are some facts to keep in mind.

Medicare Part D plans

  • The average monthly premium for a Medicare prescription drug plan in 2009 was $35.09.
  • A co-payment for medications is typical for most plans. There are four tiers of drugs and the out-of-pocket price increases as the drugs become more expensive: generic drugs, preferred brand drugs, non-preferred brand drugs, and specialty drugs
  • Not every single prescription drug on the market is typically covered by Medicare drug plans. The majority of the time a plan will cover only the generic drug rather than the brand-name drug. However, the plans are required to cover medications in all prescribed categories and classes.
  • You can appeal a decision if your plan refuses to cover a medication you need. The appeal will go through your insurer and then to an independent review body. Be sure to ask about the appeal and exception policies prior to choosing an insurer.
  • Most Medicare drug plans will require your doctor to show there is a medical reason for an expensive drug prescribed to treat an illness.

There is one major negative aspect to the Medicare prescription drug plans, often called the “donut hole” or coverage gap. There are two limits on coverage, and when the first limit is reached, you must pay 100% for medications until the second limit is reached. For example, in 2009 the average coverage gap began when a plan had covered $2,700 of medications. At that point, you had to pay for your own drugs until you had spent $4,350 out-of-pocket. Once that amount was reached, the plan picked you back up and covered most of the cost of your medications for the rest of the year.

This is a huge coverage gap for those on fixed incomes and has left many struggling. Therefore, various supplemental programs have become available to help those in the coverage gap.


Not to be confused with Medicare, Medicaid is a state-run health program for the poor and elderly. Many states are using Medicaid to help people during the coverage gap.

Discount Drug Cards

Some pharmacies offer discount cards for a small monthly fee providing money off prescription drugs. For those that can’t afford drugs not covered by their Medicare plan or when they are in the coverage gap, these cards can provide considerable assistance.

Pharmaceutical Company Patient Assistance Programs

Various drug companies have programs providing prescription drugs for low cost or free to those who cannot afford their medications. Most qualifying participants must be rejected by all forms of public assistance.

State Pharmaceutical Assistance Programs

Nearly half of all states offer financial assistance for low-income or sick senior citizens who can’t afford prescriptions.

National Prescription Drug Assistance Programs

The AIDS Drug Assistance Program and the National Organization for Rare Disorders are just two of the various organizations offering financial assistance for those with diseases requiring expensive medications.

Maintaining your health is important. Knowing what Medicare does and doesn’t cover can help you receive the proper medications at a cost you can afford.

Carrie Robertson
Research & Community Education

Chicago Senior Living
Assisted Living in Chicago

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