Exploring solutions to medication expenses

Why medication costs feel so confusing

Prescription costs vary based on your plan’s formulary, tier placement, whether a drug is a brand, generic, or biosimilar, and whether it is covered under Part D at the pharmacy or under Part B when given in a clinic or with equipment like an insulin pump. Starting in 2025, the Part D out of pocket cap makes spending more predictable across plans, and you can opt into a payment plan that smooths costs by month. Insulin has special protections that limit monthly costs when covered by Part D or by Part B for pump users.

What changed in 2025 and how it helps you

The old donut hole is gone in practice

Medicare redesigned Part D so you pay your plan cost sharing until you reach a two thousand dollar yearly maximum for covered drugs. After you reach that limit, you will not have new out of pocket drug costs for the rest of the year. Plans also offer a payment plan that lets you spread what you owe over the months of the year.

Insulin cost limits

If your insulin is covered by Part D, the plan must limit your cost for a one month supply to thirty five dollars. If you use a pump covered by Part B, Part B limits the insulin coinsurance to thirty five dollars for a one month supply and the Part B deductible does not apply to the insulin itself.

Proven ways to lower prescription costs

Ask about lower cost equivalents

• Generics are FDA reviewed for quality and work the same way as brand name drugs for most conditions.
• Biosimilars for biologic medicines are FDA reviewed to be as safe and effective as the original biologic and may cost less.
• Your prescriber can consider a therapeutic alternative in the same class that is on a lower tier of your plan’s formulary.

You can bring these options up during a visit. See our conversation tips at understoodcare.com/articles/talking-with-your-healthcare-provider

Use the right benefit for the drug

Some drugs are covered under Part B when administered in a clinic or when used with covered durable medical equipment. Most retail prescriptions are covered under Part D. Knowing which benefit applies can prevent surprise costs and help you plan refills.

Request a formulary or tiering exception when it is medically necessary

If a needed drug is not on your plan’s drug list, or it is on a high cost tier, your prescriber can request an exception with medical reasons. If the plan denies the request, you can appeal. For urgent health risks, your prescriber can request a fast decision.

Apply for help that reduces premiums and copays

• Extra Help lowers Part D premiums and out of pocket costs for people with limited income and resources. You can apply through Social Security.
• Medicare Savings Programs are state run and can help with Part A and Part B costs and may qualify you for Extra Help.
• State Pharmaceutical Assistance Programs in some states add help for drug costs and may count toward your out of pocket limit.

You can get hands on application support from our team at https://understoodcare.com/care-types/application-help

Understand how discounts work with Medicare

Federal rules generally do not allow manufacturer copay coupons to be used for drugs paid by Medicare or other federal programs. Many manufacturers operate separate patient assistance programs that may provide free medicine if you qualify. Your advocate can help you apply and coordinate with your prescriber.

How an Understood Care advocate helps you save

Help lowering prescription costs

High costs can make it hard to stick with treatment. Your advocate reviews options, compares pharmacies, and guides you through savings programs so you can focus on your health without financial stress. Learn more at https://understoodcare.com/care-types/lower-costs-of-medication

Find affordable alternatives

Your advocate checks for generics, biosimilars, and plan preferred options, then helps you talk with your prescriber about fits that protect your health and your budget.

Access discounts and assistance programs

We connect you with manufacturer patient assistance, pharmacy savings at preferred network pharmacies, state programs, and Extra Help when eligible, and we handle the back and forth to keep things moving.

Understand insurance coverage

We explain your plan’s formulary and rules such as prior authorization and step therapy, help request exceptions, and support appeals when needed.

Stay on track with your treatment

When medicines are expensive, people often delay or skip doses. We help ease the pressure by setting up refills, confirming coverage, using the monthly payment option when helpful, and troubleshooting denials so you can follow the plan your clinician recommends.

A trusted partner for medication help

Whether you take one medicine or several, your advocate works with you, your prescriber, your plan, and in some cases the manufacturer to keep costs manageable and access reliable. Start at https://app.understoodcare.com/‍

Practical steps you can take today

1. List every medicine you take, including over the counter products and supplements. Bring this list to visits.
2. Ask your prescriber if a generic, biosimilar, or lower tier alternative is appropriate for you.
3. Review your plan’s formulary and ask your pharmacy to confirm the price before you check out.
4. If a drug is not covered or is too costly, ask your prescriber to request an exception and provide clinical reasons.
5. Check eligibility and apply for Extra Help and a Medicare Savings Program.
6. If you use insulin, confirm whether it is covered under Part D or Part B and make sure the thirty five dollar monthly limit is applied correctly.
7. Consider opting into the Medicare Prescription Payment Plan so your costs are spread across the year.
8. If you feel stuck, call Medicare at 1 800 MEDICARE or chat online, or work with an Understood Care advocate to sort it out together.

When to seek more help

Reach out urgently if you are considering skipping doses due to cost. Your prescriber may have safe alternatives, samples, or documentation to support an exception. An advocate can join calls with your prescriber, prepare forms, track prior authorizations, and follow up with your plan until you have a clear path forward.

If you want help right now, visit https://understoodcare.com/care-types/lower-costs-of-medication or start at https://app.understoodcare.com/‍

Understanding Medicare Medication Costs in 2025: Frequently Asked Questions

• Why do my medication costs feel so confusing?
  Medication costs depend on several moving parts at once. Your plan’s formulary decides which drugs are covered and on what tier, which changes your copay. The price also varies based on whether the drug is brand, generic, or a biosimilar, and whether it is billed under Medicare Part D at the pharmacy or under Part B when it is given in a clinic or with equipment such as an insulin pump. These layers can make the same drug feel differently priced in different settings or at different times of the year.
• What changed for Medicare prescription costs in 2025?
  Starting in 2025, Medicare Part D has a yearly two thousand dollar cap on what you pay out of pocket for covered drugs. You pay your usual copays and coinsurance until your total out of pocket spending reaches that amount, then you do not owe more for covered Part D medicines for the rest of the year. Plans must also offer a payment option that spreads what you owe over the remaining months of the year instead of all at once, which can make budgeting easier.
• What does it mean that the “donut hole” is gone in practice?
  In the past, people moved through several phases of Part D coverage, including a coverage gap often called the donut hole. That structure has effectively been replaced by a simpler idea: you pay cost sharing up to a fixed two thousand dollar annual maximum for covered drugs, then the plan and Medicare pick up the rest. You may still see the old terms in explanations of benefits, but from your perspective the important part is the yearly cap on your out of pocket costs.
• How are insulin costs protected under Medicare?
  If your insulin is covered under Part D at the pharmacy, your plan must limit what you pay for a one month supply to no more than thirty five dollars, even if you have not met your deductible. If you use insulin in a pump that is covered under Part B as durable medical equipment, your coinsurance for that insulin is also capped at thirty five dollars for a one month supply and the Part B deductible does not apply to the insulin itself. It is still important to confirm whether your specific insulin is being billed under Part D or Part B so the cap is applied correctly.
• What can I ask my prescriber to do to lower my prescription costs?
  You can ask whether there is a lower cost equivalent that is still safe and effective for you. This might be a generic version of the same drug, a biosimilar for a biologic medicine, or a different drug in the same class that sits on a lower tier in your plan’s formulary. Your prescriber can review your conditions, other medicines, and past reactions to decide whether a less expensive option is appropriate. Bringing this up directly during visits is reasonable and can lead to meaningful savings.
• What is the difference between a generic and a biosimilar?
  A generic is a copy of a traditional small molecule drug that is reviewed by the FDA to ensure it works the same way and is as safe and effective as the brand name version for most uses. A biosimilar is the close equivalent for complex biologic medicines. Biosimilars are also FDA reviewed to show that there are no clinically meaningful differences in safety and effectiveness compared with the original biologic. Both are often priced lower than the brand or reference product.
• Why does it matter whether a drug is billed under Part B or Part D?
  Part B typically covers drugs that are given in a clinic or hospital outpatient setting or used with certain covered equipment, such as an insulin pump. Part D covers most retail prescriptions you pick up at a pharmacy. The benefit used affects your deductible, coinsurance, and which spending counts toward the Part D two thousand dollar cap. Knowing which benefit applies can help you anticipate costs, understand your explanation of benefits, and identify errors if a claim seems out of place.
• What is a formulary or tiering exception and when should I ask for one?
  A formulary exception is a request for your plan to cover a drug that is not usually on its covered list. A tiering exception is a request to treat your drug as if it were on a lower cost tier so you pay less. Your prescriber must explain why you medically need that specific medicine, for example if you tried and could not tolerate alternatives, or they are not appropriate for your condition. You might ask for an exception if a needed medicine is not covered at all, or if the copay is very high and lower tier options are not suitable. If the plan denies the request, you have the right to appeal, and in urgent situations a fast decision can be requested.
• What programs can help me with premiums and copays for medicines?
  Extra Help is a federal program that lowers Part D premiums and reduces copays for people with limited income and resources. Medicare Savings Programs are run by states and can help with Part A and Part B costs and may also qualify you for Extra Help. Some states offer State Pharmaceutical Assistance Programs that provide additional help with drug costs and may count toward your out of pocket limit. An advocate or counselor can help you check eligibility and complete applications if the paperwork feels overwhelming.
• Can I use manufacturer copay coupons with Medicare?
  Federal rules generally do not allow manufacturer copay coupons or cards to be used for medicines that are paid for by Medicare or other federal programs. This is why you often see fine print that excludes federal beneficiaries. However, many manufacturers run separate patient assistance programs that may provide free or heavily discounted medicine if you meet income and other criteria. These programs usually require forms from you and your prescriber. An advocate can help you find the right program, complete the paperwork, and follow up on decisions.
• How can an Understood Care advocate help lower my medication costs?
  An advocate can review all of your medicines, identify where costs are highest, and see whether generics, biosimilars, or lower tier options exist that still fit your medical needs. They can help you prepare questions for your prescriber about switching safely, compare prices across pharmacies in your plan’s network, and identify preferred pharmacies with better copays. Advocates can also connect you with Extra Help, Medicare Savings Programs, state assistance, and manufacturer patient assistance, and then handle much of the follow up and document gathering so you do not have to manage it alone.
• How can an advocate help me understand my insurance coverage and rules?
  Your advocate can walk you through your plan’s formulary so you know which drugs are on which tiers and what that means for cost. They can explain requirements such as prior authorization, step therapy, or quantity limits and help your prescriber supply the right information. If a drug is denied, an advocate can help you request an exception or file an appeal, track decisions, and coordinate with your prescriber so you have a clear plan instead of being stuck at the pharmacy counter.
• What practical steps can I take right now to manage medication costs?
  You can start by making a single up to date list of every medicine you take, including prescriptions, over the counter products, and supplements, and bringing it to every visit. Ask your prescriber whether each medicine still needs to be continued and whether a generic, biosimilar, or lower tier option would be safe for you. Review your plan’s formulary and ask your pharmacy to tell you the expected price before you check out, especially when starting a new drug. If a medicine is not covered or is too expensive, ask your prescriber to request a formulary or tiering exception and provide medical reasons. Check whether you qualify for Extra Help or a Medicare Savings Program, and if you use insulin, confirm how it is being billed and whether the thirty five dollar monthly limit is being applied correctly. You can also consider enrolling in the Medicare Prescription Payment Plan so your annual costs are spread more evenly across the year.
• What should I do if I am thinking about skipping doses because of cost?
  Reach out to your prescriber or care team before you skip or stretch doses. Suddenly cutting back on medicines, especially for heart disease, diabetes, mental health, or breathing problems, can be dangerous. Your prescriber might have safer alternatives, sample packs, different dose strengths, or medical reasons that support a formulary exception. An advocate can help you describe your situation clearly, join calls with your prescriber if you wish, complete forms for savings programs, and follow up with your plan so you can land on an affordable plan that still protects your health.
• How can I get personal help with my medication costs right now?
  If you feel stuck or overwhelmed, you can talk with Medicare directly by calling 1 800 MEDICARE or using the online chat, or you can work with an Understood Care advocate who regularly helps patients sort out coverage, costs, and savings options. They can review your medicines, explain the new 2025 rules in plain language, help you apply for Extra Help or other programs, and stay with you through appeals or prior authorizations until there is a clear and sustainable plan.

References

• Medicare Part D Improvements and 2025 redesign
  https://www.cms.gov/priorities/medicare-prescription-drug-affordability/overview/medicare-part-d-improvements
• Medicare Prescription Payment Plan overview
  https://www.cms.gov/medicare/health-drug-plans/medicare-prescription-payment-plan
• Medicare fact sheet on the Payment Plan and the two thousand dollar cap
  https://www.medicare.gov/publications/12211-whats-the-medicare-prescription-payment-plan.pdf
• Medicare drug costs help and Extra Help program
  https://www.medicare.gov/basics/costs/help/drug-costs
• Apply for Extra Help through Social Security
  https://www.ssa.gov/medicare/part-d-extra-help
• Medicare Savings Programs description
  https://www.medicare.gov/basics/costs/help/medicare-savings-programs
• State Pharmaceutical Assistance Programs and how they may count toward the out of pocket limit
  https://www.medicare.gov/health-drug-plans/part-d/basics/costs
• Insulin coverage and thirty five dollar monthly limits
  https://www.medicare.gov/coverage/insulin
  https://www.cms.gov/files/document/mln4443820-billing-medicare-part-b-insulin-new-limits-patient-monthly-coinsurance.pdf
  https://www.medicare.gov/publications/12172-3-things-to-know-about-medicare-insulin-costs.pdf
• Part B drugs and when Part B applies
  https://www.medicare.gov/coverage/prescription-drugs-outpatient
  https://www.cms.gov/cms-guide-medical-technology-companies-and-other-interested-parties/payment/part-b-drugs
• Formulary and tiering exceptions and appeals
  https://www.medicare.gov/health-drug-plans/part-d/what-drug-plans-cover/how-drug-plans-work
  https://www.cms.gov/medicare/appeals-grievances/prescription-drug/exceptions
  https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals/drug-plans
• FDA resources on generics and biosimilars
  https://www.fda.gov/drugs/biosimilars/biosimilars-basics-patients
  https://www.fda.gov/drugs/biosimilars/biosimilar-product-information
• OIG Special Advisory Bulletin on manufacturer coupons and federal programs
  https://oig.hhs.gov/documents/special-advisory-bulletins/806/SAB-Copayment-Coupons-2014.pdf

This content is for education and does not replace medical advice from your clinician. If you have urgent questions about your medicines or symptoms, contact your healthcare provider or call 911.