Early in the new year in 2025, I have already received several calls from clients surprised and worried about the high cost of their first prescription refill. These are the same drugs they have always been on, so why in the name of happy pills is the cost suddenly so high? What happened and is there anything that can be done? Well, read on for both an explanation and some helpful tips to manage those costs!
Inflation Reduction Act Strikes Again
Two major pieces of the Inflation Reduction Act hit in 2025 causing this shift in higher drug copays to the beginning of the year. The combination of the removal of the donut hole and the $2000 annual cap on copays led to this shift. Insurance companies had to increase the drug deductible on existing plans or add a drug deductible to plans that did not have one in 2024. I have written about it, posted videos and provided multiple educational events attempting to prepare everyone. In meeting with clients during open enrollment, I also provided the estimates for drug copays for each month of 2025. [Note- please reach out if you need a new copy, refresher or new quote] However, with the overwhelming amount of information hitting Seniors each year, it is understandable that all is forgotten until standing at the pharmacy counter picking up that first refill. It can be very unsettling, but there is hope. There are strategies you can use to help minimize the high upfront cost and still get your needed medications!
M3P
CMS anticipated higher upfront costs this year due to the changes. They introduced the M3P initiative to ease the financial strain some will experience. M3P is the new Medicare Prescription Payment Plan. The goal is to ‘smooth’ out the costs over the course of the year for certain beneficiaries whose costs will likely hit the $2000 cap. Beneficiaries can enroll in the M3P at the time they sign up for their new stand-alone drug plan or Advantage Plan with drug coverage. Once you opt in to M3P, you will be issued a monthly payment plan to normalize drug costs and spread it over the course of the year. So, you will pay nothing at the pharmacy to pick up your drugs but will be billed monthly by the insurance company or a third party. You can also enroll in this plan anytime throughout the year, which helps if you get prescribed a new high-cost drug mid-year. To be clear, it does not change the total annual cost of your drugs. It just spreads the payments out more evenly over the course of the year, so you do not have those big hits at the beginning of the year at the pharmacy.
Extra Help
This program for help with prescription drug costs is not new, but many do not realize it is out there or that they may qualify. This is a low income subsidy, not Medicaid, but rather through Medicare that if you qualify, helps pay the copays for high cost drugs and premiums for prescription drug plans. There are different income thresholds than with Medicaid through the state, so there are more people who qualify. It is a simple application that can be done online and at any time throughout the year. See the link below for more information. There is also a previous blog post specifically about the Extra Help program written by a pretty savvy Independent Insurance Agent…..wink, wink.
GoodRx
In some cases, you can find a better and lower copay on your medication through the GoodRx discount program. There are also many other discount programs. Some of the Advantage Plans even offer an additional pharmacy discount program if you use their mail order. As a Medicare Beneficiary, you do not necessarily HAVE to use your Par D plan to get your prescriptions filled. You can compare the price on your plan to the price using a discount program like GoodRx and then choose which one to use. Just know that if you use GoodRx, that copay does not go toward your Part D plan deductible. This could lead to a delay getting to your deductible, which lowers your copays. But discount programs are an option to certainly explore!
Talk to Your Doctor
If none of these three strategies work for you, and you are still going to struggle paying for your medication, please reach out to your provider. There may be alternative, lower cost medications that are safe and effective for your condition! Do not just go without your important healthcare treatments! Many times, providers are just not paying that close attention to the plan costs and copays. They do care but are just inundated with all the other pieces of their important work. Be sure to advocate for your health and reach out for a solution. I often utilize the services of the highly qualified Nurse Practitioners and Physician Assistants at my Doctor’s office. You may also get fast service through virtual visits, which Medicare supports! Sounds like a topic for another blog, so stay tuned!
CDI is here to help you manage your healthcare costs and find the best options for your unique situation. We can meet in person or virtually. Reach out if you would like more information. Email carrie@cdi-cares.com or check out www.cdi-cares.com for a contact page and other helpful blogs.
Resources:
https://www.ssa.gov/medicare/part-d-extra-help
