How Advocates Help Patients Access Affordable Medication

Introduction

If the cost of medicine is getting in the way of your health, you are not alone. Older adults often skip refills or split pills because of price concerns. An advocate can step in to lower costs, prevent mistakes, and coordinate with your doctor and pharmacist so you can stay on your treatment plan. [NCHS reports cost related medication challenges among older adults, which underscores why this support matters]. CDC

Advocates with Understood Care help you compare safe options, request insurance exceptions, and find financial assistance programs. You can also learn more about our direct support at https://understoodcare.com/care-types/lower-costs-of-medication and how we coordinate with your care team at https://understoodcare.com/care-types/care-coordination

What your advocate actually does when you call

We start with the details that drive the price. During your first call, we ask for the exact medication name, dose in milligrams, how often you take it, the pharmacy you use, and your plan information. With that, we can:

• Confirm the pharmacy is charging the correct amount under your plan and spot billing errors quickly
• Run real price checks across reputable savings programs and cash prices to see whether a lower price is available at a different pharmacy
• Compare cost and coverage for therapeutically equivalent options, then coordinate with your prescriber if a change makes sense
• Explain when to use your insurance and when a discount price may be better for a one time fill, including what that means for your plan spending total

From the video, here is how that looks in practice. Debbie from Understood Care explains that many people have seen savings program commercials. If a verified discount price is lower than your copay, you can ask the pharmacist to process the prescription as a cash transaction using that discount. Large chains sometimes promote price comparisons in ads, but they may not volunteer the lowest price at the counter. Your advocate will check multiple programs for you, confirm your plan is charging correctly, and make sure you are not overcharged. There are many options, and you do not have to sort them alone.

Proven ways to lower your medication costs

Ask about generics and equivalent options

FDA approved generics must have the same active ingredient, strength, dosage form, route of administration, and clinical effect as the brand name medicine. Generics typically cost less and work the same for most people. We can prepare a one page note for your prescriber with equivalent options to consider and send it to your pharmacy once approved.

Use your plan rules to your advantage

Medicare drug plans use rules like prior authorization, step therapy, and quantity limits. When a rule blocks access or raises your cost, your advocate can request a coverage determination and, when appropriate, a formulary or tiering exception with supporting medical notes. If the plan denies the request, we help you file an appeal and track the deadlines.

Apply for Extra Help if you qualify

Extra Help is a federal program that lowers premiums and reduces copays for people with limited income and resources. Many people who qualify are not enrolled. We screen you, complete the application, and follow through with Social Security and your plan. Medicare

For step by step application support, visit https://understoodcare.com/care-types/application-help

Consider the Medicare Prescription Payment Plan

Starting in 2025, you can choose to spread your out of pocket prescription costs for covered Part D drugs into monthly bills from your plan. This option can make expenses more manageable during the year, although it does not reduce the total you owe. Your advocate can explain whether it fits your situation and help you enroll with your plan.

Check trusted assistance programs

Depending on your medications and your state, added help may be available

• State Pharmaceutical Assistance Programs can offset premiums or copays. Some payments may count toward your annual Medicare drug spending total
• Pharmaceutical Assistance Programs from manufacturers can sometimes help if you meet eligibility rules
  Your advocate confirms eligibility, completes applications, and tracks each step so nothing gets lost.

When to use a discount price and when to use your plan

Discount cards and pharmacy cash prices are not insurance. You generally cannot combine them with your Medicare drug plan for the same fill. If a cash price is lower than your copay, using the cash price can make sense for that fill, but it usually will not count toward your Medicare out of pocket spending total for the year. We will compare both options and explain the tradeoffs before you decide.

Pharmacists are allowed to tell you when a lower cash price is available. Federal rules prohibit gag clauses that used to stop pharmacies from sharing lower price options with Medicare beneficiaries. Still, many systems do not automatically show the lowest price, so asking is important. Your advocate will ask for you and document the answer.

Important note about manufacturer copay coupons. Federal guidance warns that copay coupons from drug manufacturers cannot be used for medicines paid by Medicare Part D. If a manufacturer coupon seems attractive, we will help you review compliant alternatives such as independent charity programs or formulary exceptions.

How we coordinate with your doctor and pharmacy

One medication list, shared safely. We create a current list that includes each medicine, dose, timing, prescriber, and pharmacy. With your permission, we share cost saving options and prior authorization details with your care team and send updates when anything changes.

Clear next steps after every call. You get a written summary that includes which price option we recommend, whether we are filing a coverage determination or appeal, what your doctor needs to sign, and when you should expect the next update.

Medication Therapy Management. If you qualify for your plan’s Medication Therapy Management program, we encourage you to complete a comprehensive medication review with the plan pharmacist and we can join the call if you want an extra set of ears.

When to call an advocate right away

• Your copay suddenly increased or a refill was denied
• Your pharmacy says a prior authorization or step therapy is required
• You are choosing between a discount price and your insurance and you want to understand the effect on your yearly spending total
• You may qualify for Extra Help or a state program and need application support
• You want your doctor to consider a generic or lower tier alternative and you would like help preparing the request

Understood Care is ready to help. You can start here https://understoodcare.com/care-types/lower-costs-of-medication

What to expect from Understood Care

• A single point of contact who knows your medications and your plan rules
• Verified price checks across your plan, preferred pharmacies, and reputable savings programs
• Exception and appeal support with complete clinical notes and follow up
• Application help for Extra Help, manufacturer assistance where allowed, and state programs
• Coordination with your prescriber to request safe, comparable alternatives when they make sense
• Clear summaries after every step so you always know what is next

FAQ: Getting Help With High Medication Costs

• What does Understood Care do if my medications are too expensive?
  If the cost of your medicine is getting in the way of your health, an Understood Care advocate steps in to lower costs, prevent mistakes, and coordinate with your doctor and pharmacist. We help you understand your options, look for safer and more affordable alternatives, and organize the steps so you can stay on your treatment plan without skipping doses or splitting pills because of price.
• What information do I need when I first talk with an advocate?
  During your first call, your advocate will ask for the exact medication name, the dose in milligrams, how often you take it, which pharmacy you use, and your insurance or Medicare plan information. With these details, we can verify pricing, check coverage, and look for savings programs that fit your situation.
• How does my advocate check if I am being charged the right amount?
  Your advocate confirms that the pharmacy is using the correct billing under your plan and checks for errors such as wrong copays or missing discounts. We then compare your plan price with reputable cash and savings program prices to see if another pharmacy or pricing option could safely lower what you pay.
• Can my advocate help me find a cheaper but similar medication?
  Yes. We compare cost and coverage for therapeutically equivalent options, such as generics or lower tier drugs in the same class. If a safe alternative makes sense, we coordinate with your prescriber to request a change and send updated information to your pharmacy once it is approved.
• When is it better to use my insurance and when is a discount price better?
  You generally cannot use a discount card and your Medicare drug plan for the same prescription fill. If a verified cash or discount price is lower than your copay, it may make sense to use that price for a one time fill. The tradeoff is that most cash prices do not count toward your yearly Medicare out of pocket total. Your advocate will compare both options and explain how each choice affects your costs over the year before you decide.
• Will my pharmacist tell me if a cash price is lower than my copay?
  Pharmacists are allowed to tell you when a lower cash price is available, and federal rules prohibit “gag clauses” that used to prevent this. In practice, pharmacy systems do not always show the lowest price automatically, and staff may not volunteer it. Your advocate will ask the pharmacy directly, document the answer, and help you choose the best option.
• How can generics and equivalent options lower my costs?
  FDA approved generics must have the same active ingredient, strength, dosage form, route of administration, and clinical effect as the brand name medicine. They usually cost less and work the same way for most people. Your advocate can prepare a short summary for your prescriber that lists covered generics or lower tier options and help send a new prescription to the pharmacy if your doctor agrees.
• What if my plan requires prior authorization, step therapy, or has a quantity limit?
  Medicare drug plans often use these rules to control costs. If a rule blocks access to a medication or makes it more expensive, your advocate can request a coverage determination from the plan. When it is medically appropriate, we help your prescriber request a formulary or tiering exception and provide supporting medical notes. If the plan denies the request, we guide you through the appeal process and track all deadlines.
• Can I get help from Extra Help or other assistance programs?
  Yes. Extra Help is a federal program that lowers Part D premiums and reduces copays for people with limited income and resources. Many eligible people are not enrolled. Your advocate can screen you for eligibility, complete the application, and follow through with Social Security and your plan. We also look for State Pharmaceutical Assistance Programs and manufacturer Patient Assistance Programs when allowed, then complete forms and track responses so steps are not missed.
• What is the Medicare Prescription Payment Plan and how can an advocate help?
  Starting in 2025, the Medicare Prescription Payment Plan lets you spread what you owe for covered Part D medicines into monthly bills from your plan instead of paying large amounts all at once. This does not reduce the total cost, but it can make payments more manageable. Your advocate can explain how the program works, help you decide if it fits your situation, and assist with enrollment through your plan.
• Can I use manufacturer copay coupons with Medicare?
  Federal guidance warns that drug manufacturer copay coupons generally cannot be used for medicines paid by Medicare Part D or other federal programs. If a coupon looks appealing, your advocate will help you look at alternatives such as independent charity programs, formulary exceptions, or other assistance that complies with federal rules.
• How does Understood Care coordinate with my doctor and pharmacy?
  We create one up to date medication list that includes each medicine, dose, timing, prescriber, and pharmacy. With your permission, we share cost saving options, prior authorization details, and formulary exception requests with your care team. We also send updates when anything changes, so your doctor, pharmacy, and advocate are all working from the same information.
• What follow up can I expect after I talk with an advocate?
  After each call, you receive a clear summary that explains which price option we recommend, whether we are filing a coverage determination or appeal, what your doctor needs to review or sign, and when you should expect the next update. If you qualify for your plan’s Medication Therapy Management program, we encourage you to complete a comprehensive medication review and can join that call if you want added support.
• When should I call an advocate right away about medication costs?
  Reach out quickly if your copay suddenly increases, a refill is denied, or your pharmacy says a prior authorization or step therapy is required. It is also a good time to call if you are deciding between a discount price and using your insurance, think you might qualify for Extra Help or a state program, or want your doctor to consider a generic or lower tier option and you would like help preparing that request.
• What ongoing support does Understood Care provide for medication costs?
  Understood Care offers a single point of contact who learns your medications and your plan rules, verifies prices across your plan and trusted savings programs, supports exceptions and appeals with complete documentation, and helps with applications for Extra Help, manufacturer assistance where allowed, and state programs. We coordinate with your prescriber to request safe alternatives when they are appropriate and provide clear summaries after each step so you always know what is happening and what comes next.

References

1. https://medlineplus.gov/financialassistancemedicines.html
2. https://www.medicare.gov/health-drug-plans/part-d/basics/extra-help
3. https://www.ssa.gov/benefits/medicare/prescriptionhelp
4. https://www.cms.gov/medicare/appeals-grievances/prescription-drug/coverage-determinations
5. https://www.medicare.gov/health-drug-plans/part-d/what-drug-plans-cover/plan-rules
6. https://www.fda.gov/drugs/generic-drugs/generic-drug-facts
7. https://www.fda.gov/media/111058/download
8. https://www.medicare.gov/prescription-payment-plan
9. https://www.cms.gov/medicare/health-drug-plans/medicare-prescription-payment-plan
10. https://www.medicare.gov/health-drug-plans/part-d/basics/costs
11. https://www.cdc.gov/nchs/data-reporting/older-adult-health.htm
12. https://www.cms.gov/medicare/coverage/prescription-drug-coverage-contracting/medication-therapy-management
13. https://www.medicare.gov/health-drug-plans/part-d/basics/creditable-coverage
14. https://www.federalregister.gov/documents/2019/05/23/2019-10521/modernizing-part-d-and-medicare-advantage-to-lower-drug-prices-and-reduce-out-of-pocket-expenses
15. https://oig.hhs.gov/compliance/alerts/special-advisory-bulletins
16. https://oig.hhs.gov/reports/all/2014/manufacturer-safeguards-may-not-prevent-copayment-coupon-use-for-part-d-drugs

This content is educational and is not a substitute for medical advice. Always consult your healthcare provider for personalized care.