Q: My mother has Original Medicare and a Part D prescription drug plan. She takes several medications, and her drug costs are too high for her to afford. She does not qualify for Extra Help and her state does not have a State Pharmaceutical Assistance Program. What else can we try to lower her drug costs?
A: If Extra Help and State Pharmaceutical Assistance Programs (SPAPs) are not options for your mother, there may be other programs and strategies she can use to save money on drug costs. You or your mother should contact her State Health Insurance Assistance Program (SHIP) to learn if any of the following programs are available for her in her area (if you don’t know how to contact her SHIP, call 877-839-2675 or visit www.shiptacenter.org):
Charity programs: There may be charities that can help reduce your mother’s prescription costs.
Patient Assistance Programs (PAPs): Your mother may be eligible to get free or low-cost drugs directly from the company that makes them, through a PAP. In most cases, a patient’s doctor must apply for them. Not all PAPs allow people with Part D to apply.
Prescription drug discount programs: Your mother may be able to get medications she needs at a reduced price from a national or local discount program. Note that she cannot use a prescription drug discount program and Part D coverage at the same time: she must select between them at the pharmacy.
Safety net providers: Pharmacies in certain government-funded hospitals and community health centers may provide medication at lower costs or charge people based on income. These centers and clinics include federally qualified health centers (FQHCs) and rural health clinics (RHCs). Some centers may waive copays for drugs covered by your mother’s Part D plan if she requests assistance. Be sure to contact the facility directly to learn which benefits it offers.
There are also steps that your mother may want to take when she speaks to her provider, plan, pharmacy or hospital. You or your mother can consider these strategies:
Ask her doctor about generics: Generic drugs are often less expensive than brand-name drugs, and might be more affordable. Your mother’s doctor may be able to find a generic drug that works for her.
Ask her doctor about samples of her medication: This is a temporary solution, as her doctor may not be able to provide samples for long, but may provide access in an emergency.
Ask her plan about a tiering exception: If her Part D plan is covering her drug and the copayment is expensive, it could be that the medication is on a high tier. A tiering exception request is a way to lower cost-sharing.
Ask her pharmacy to waive her copay: Pharmacies are not allowed to routinely waive their copays for people without Extra Help, but her pharmacist can waive copays on a case-by-case basis. Your mother can tell her pharmacist that she cannot afford the copay, and request that it be waived. You should make sure that the pharmacy is in your mother’s plan’s network.
Ask at the hospital about charity care: Hospitals may have a charity care policy that can reduce drug copays if your mother cannot afford them. Under such a policy, your mother’s final copay is determined by income (using a sliding scale). To qualify, your mother’s prescription must be written by a doctor in the hospital and filled out at the hospital’s pharmacy. Your mother should check that the hospital’s pharmacy is in-network, then should tell the hospital’s pharmacist that she cannot afford the copay and ask if she qualifies for prescription assistance.
Review her coverage in the fall (or sooner if a Special Enrollment Period applies): Though it may not provide immediate relief, your mother should carefully consider her plan options during Fall Open Enrollment. Another Plan in her area may have lower cost sharing for the drugs she takes.