Feeling the pinch?

Skipping drug doses because you can’t afford to refill your prescriptions?

(Or skipping refills altogether)?

Prescription costs may be one of the most frustrating things to face in retirement.

Here are 4 ways to Get Help Paying for Prescriptions on Medicare

1.) A Medicare Program for prescriptions, called “Extra Help”

If your income is low and you are struggling, I recommend applying for Extra Help.

Extra Help” (also known as Low Income Subsidy) is the name of a Medicare program to help people on Medicare with limited income and resources pay for prescription drugs.

This extra help works in conjunction with Medicare Part D.  That means you must enroll, or already be enrolled in, a Medicare Part D drug plan.

How to know if you qualify for extra help:

According to Medicare.gov, in order to qualify in 2016, you’re allowed to  have up to $17, 820 annual income ($24,030 for married couples).

You can have resources totaling $13,640 ($27,250 for married couples).

Resources include checking or savings accounts, stocks, or bonds, and does not include your home, car, or personal possessions.

See the complete listing of qualifications to save on drug costs, at Medicare.gov.

According to Kaiser Family Foundation, over 11 million (30% of Medicare Enrollees) qualify for the low income subsidy (LIS) for Medicare Part D prescription drugs.

Get Help Paying for Prescriptions on Medicare

*The above graphic was taken from the publication “Things to Think About When You Compare Medicare Drug Coverage.”

2.) Your state Medicaid Program

Medicaid is a social healthcare program that helps with medical costs for people of all ages.

It is jointly funded through federal and state sources, but regulated by each state.  Therefore each state’s Medicaid program may vary and you must apply through your state Medicaid office.


Medicaid.gov Spend Down Program

Unlike Medicare, Medicaid assistance is based on need, while Medicare is based on age eligibility among other factors.

An individual may receive both Medicare and Medicaid benefits.

If you are struggling with Medical expenses but not eligible for Medicaid, you might still get help through the “spend down” rules.

Some states allow those with incomes over the allowed amount to subtract medical expenses from their income to become eligible for Medicaid.

According to Medicare.gov,

You may be eligible for extra help paying for Medicare prescription drug coverage (Part D),

even if your income exceeds Medicaid income levels, under the spend down rules if you are

medically needy.

Check with your state Medicaid office to see you qualify.

3.) Medicare Savings Programs

Medicare Savings Programs are state sponsored and may help pay for Medicare Part A & B premiums, deductibles, and coinsurance.

Obviously this isn’t direct help with your prescription costs, which is the topic of this post, but it can go a long way to ease the burden of medical costs in general.

There are four levels of help:

  1. Qualified Medicare Beneficiary Program (QMB)
  2. Specified Low-Income Medicare Beneficiary Program (SLMB)
  3. Qualifying Individual Program (QI)
  4. Qualified Disabled and Working Individuals Program (QDWI)

Here are the Income requirements for each (Each State ultimately decides whether or not you qualify [and some are more flexible than others], so you must apply through your state’s Medicaid office).

Medicare Savings Programs income levels

Before considering applying, can you answer yes to the following three questions?

  1. Do you have Medicare Part A?
  2. Are your income levels at or below the above amounts?
  3. Are your resources limited?

Medicare.gov recommends filling out an application, even if your income is above the amounts shown.

4.) Pharmaceutical Assistance Programs

Pharmaceutical Assistance programs offer financial assistance through Pharmaceutical companies, or  State programs.

Drug Companies

Click here to go to the Pharmaceutical Assistance Program Search Tool for drug companies.

This search tool, located on Medicare.gov, allows you quickly and easily determine if your brand drug’s manufacturer offers assistance under the Pharmaceutical Assistance program.

Simply click the corresponding letter of the alphabet that your drug begins with.  You’ll be redirected to a list of drugs under that letter.

If you find your drug on the list, click the drug name to obtain details about the application process for obtaining assistance.

State Programs

As of 2016, there are 22 states that offer help through State Pharmaceutical Assistance Programs.

Click here to go the the State Pharmaceutical Assistance search tool.

Select your state in the drop down menu to be redirected to details about your state’s program.

What if none of the above applies to you?

You might feel frustrated and left out if you don’t qualify for the above programs.

I want you to know there’s some other ways to save that might surprise you!

Switch to generics.

Yes, switching to generics seems obvious, and I realize it’s not always possible.

But this is a strategy you shouldn’t overlook.

Not only can choosing generics prevent you from entering the Part D donut hole, but it contributes to the fight against rising healthcare costs.

As quoted by the Generic Pharmaceutical Association’s 2015 Generic Savings report:

According to the 2014 Express Scripts Drug Trend Report,

since 2008, the price of brand drugs has almost DOUBLED;

but the price of generic drugs has been roughly cut in half.

Choosing generics contributes to the savings of our healthcare system, and lowers costs for everyone over time.

Screen Shot 2016-05-03 at 12.10.15 PM

According to the Generic Pharmaceutical Association’s 2015 Generic Savings report, Medicare saved 76.1 billion in 2014 through the use of generics over brand drugs.

So how do you avoid the Donut Hole by using generics?

The Donut Hole is a gap in your Part D prescription coverage.  Once the full cost of your medications adds up to a certain amount (this amount changes each year and is determined by Medicare), you’ve hit the Coverage Gap, or Donut Hole.

In the Donut Hole your cost sharing goes up. 

Lowering your drug costs overall, by purchasing generics, will help prevent you from reaching the coverage gap.

Another strategy is to pay for drugs out of pocket, rather than through your drug plan.  This means the claims are not submitted through the plan.

This sounds a bit crazy at first, but the cost of some generic drugs are can be similar in price, or even lower than some plan drug copays.   Also, some pharmacies offer special programs, such as free generics for certain common drugs.

By paying a low cost out of pocket, instead of submitting the claim through your drug plan, this prevents these drugs from being added to the cost toward the coverage gap limit.

Therefore you will reach the gap later in the year, or not at all, in most cases.

Review your drug plan and make changes during open enrollment.

Another obvious tip, but you’d be surprised how many folks avoid checking their plan changes and end up shelling out hundreds, or even thousands more each year because of this oversight.

There are countless articles and news sources warning Medicare enrollees to not skip this important step!

Each year, starting on October 15th, you may review your drug coverage (whether it’s a stand-alone plan, or part of a Medicare Advantage Plan), and switch plans.

Plans often make changes such as adding or removing pharmacies from their network, changing a pharmacy’s status from preferred to standard, dropping covered drugs, changing a drug’s tier, or changing copay amounts.

I have reviewed my own client’s plans and have seen first hand the changes plans make, that the client is completely unaware of.

You must be vigilant, and if you misplace your Annual Notice of Changes letter, it’s up to you to either call medicare, the plan, or your agent, to find out what the changes are, before it’s too late.

hourglass at sunset

If you are taking a therapeutic drug that you cannot be without, and your plan drops the drug for next year, you could be responsible for the full cost of the drug.

Some carriers may choose to cover your drug if you submit an appeal.  But there is no guarantee.  It is better to shop around first, before you’re hit with a potential surprise, come January 1st.

In Conclusion

The following programs may help you get help paying for prescriptions on Medicare:

1.) Medicare’s “Extra Help” or Low Income Subsidy (LIS)


3.)Medicare Savings Programs

4.)Pharmaceutical Assistance Programs

If you don’t qualify for the above programs, you can find relief by using generic drugs when possible.

Make it a habit to review your coverage each year during the open enrollment period.  This will avoid any surprises and help keep costs down over time.