2026 Prescription Drugs

Just a note:  Most Medicare Prescription Drug plans for 2026 have a drug deductible on tiers 3-5, even on Medicare Advantage Plans.  Knowing that this deductible can be equal to some people's rent or house payment, this is trying for people with limited income.  I just have a few reminders for my fellow advocates as to how you may give assistance.  

1. Some prescriptions are less expensive with a coupon found online, such as «goodrx.com» and other sites. Example: Atorvastatin with a good rx coupon is $25 at Walmart. This drug could hit some Part D deductibles which are $200- $615. If purchased with a coupon it never goes through insurance and bypasses hitting that deductible. The patient would just pay the $25 coupon price. It is likely that this coupon price is less than the co-pay would be after the deductible is met, so depending on the persons other drug costs, it could be best to simply use the coupon and not insurance.

2.  If there is a prescription or even a group of prescriptions that is more than one can financially bear, there is a program called the Medicare Prescription Drug Payment Program that is in its second year in 2026. If someone is on Medicare and their prescription(s) is too expensive, they can call their plan and get set up on a 12 month payment plan, spreading the cost over 12 months. You can begin or add to this plan throughout the year.

3.  If a prescription drug is simply unaffordable and your Medicare Part D plan prohibits the senior from joining a manufacturer's co-pay program (which is often), watch for the words, «if you are underinsured» in the language of the co-pay card eligibility.  Some co-pay cards prohibit those with Part D plans and some will allow seniors to qualify for the co-ay card if they are «underinsured.» If the patient portion is financially out of reach, they could be considered «underinsured.»  In this case, they can proceed to register for the co-pay card and it is possible that it will be approved.

4.  For those who are on prescriptions where none of these options are available, there are Patient Assistance Programs that are through the manufacturers.  These programs are sometimes hard to find as they are hidden in language and sometimes on separate websites and under other company names.  Some are offered through non-profit organizations.  These programs are usually income driven and often used by people who are not eligible for Extra Help, but still cannot afford a prescription.  There is usually a two page application.  The patient portion is very east and not complicated, the second portion is to be filled out by the prescribing physician and sent to the manufacturer by the physician.  Most physicians are familiar with these programs but it is usually on the patient to get the application, fill out their part and then take it to their physician who does the rest.  There are too many circumstances spread over a physicians patient group to add «financial counseling» to their job description.  Therefore, that falls back to us as Medicare consultants and Advocates.

5.  Remember, the patient can always ask for the physicians help in finding a drug that better fits their formulary.  That is something the doc can assist with.

6. If a drug is not on a patients formulary, the doc can ask for an exception for that patient.  Also, they can request a tier exception which can bring a drug down a tier so that the cost is less.  This is widely unknown.  The insurance companies will often do this.

7.  Always ask the pharmacist for coupon help.  This week I had a client that was prescribed Paxlovid and it was a Tier 3 drug and she had a $500 deductible.  It was going to cost her $580 and she is on a fixed income.  She was very upset and her daughter called me while at the drive through window at the pharmacy.  While I was on the phone, the pharmacist came to the window and said, «no worries, I found a coupon for $0, there will be no charge.»  I looked online to see if I could find the coupon they used and found that it is only for «providers.»  That coupon was not available to the consumer, so ask!

8.  If you feel your client could qualify for Extra Help with drugs, you can assist them in applying.  www.ssa.gov (go to Apply for Extra Help) This program will help pay deductibles, reduce the cost of co-pays and sometimes help with Part D premiums.

9.  Lastly, don't ever forget to remind your clients to ask their physician for samples while your client navigates how to pay for what has been prescribed.

Hope this helps!  Thanks for being an advocate!