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.

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/‍

FAQ

• Why do my medication costs feel so confusing?
  Medication prices depend on several moving pieces: your plan’s formulary, the tier a drug is placed on, whether it is brand, generic, or a biosimilar, and whether it is covered under Part D at the pharmacy or under Part B in a clinic or with equipment like an insulin pump. These factors change from drug to drug and plan to plan, which is why costs can feel unpredictable.
• What changed in 2025 for Medicare drug coverage and how does it help me?
  Starting in 2025, Part D was redesigned so you pay your usual cost sharing until your total yearly out of pocket costs for covered drugs reach two thousand dollars. After you reach that cap, you do not pay more out of pocket for covered Part D drugs for the rest of the year. Plans also offer a payment option that lets you spread what you owe into predictable monthly amounts.
• How are insulin costs limited under Medicare now?
  If your insulin is covered by Part D, your plan must limit your cost for a one month supply of each covered insulin to thirty five dollars. If you use an insulin pump that is covered under Part B, Part B also limits your monthly coinsurance for insulin used with the pump to thirty five dollars and the Part B deductible does not apply to the insulin itself.
• How can asking about lower cost equivalents reduce my prescription costs?
  Generics are FDA reviewed for quality and are expected to work the same way as brand name drugs for most conditions, usually at a lower cost. Biosimilars are FDA reviewed versions of biologic medicines that are as safe and effective as the original and may be less expensive. In some cases, a different medicine in the same class that is on a lower tier of your plan’s formulary can meet your needs. You can ask your prescriber during a visit whether a generic, biosimilar, or lower tier alternative is appropriate for you.
• Why does it matter whether a drug is covered under Part B or Part D?
  Some medications are billed under Part B when they are administered in a clinic or used with covered durable medical equipment. Most retail prescriptions are billed under Part D. Knowing which benefit applies can help you avoid surprise bills and plan for your copays and coinsurance, especially for high cost drugs or infusions.
• What is a formulary or tiering exception and when should I ask for one?
  If a needed medicine is not on your plan’s formulary, or it is placed on a high cost tier, your prescriber can ask the plan for an exception and explain the medical reasons you need that specific drug or tier change. If the plan denies the request, you can appeal their decision. For urgent health issues, your prescriber can request a fast decision so treatment is not delayed.
• What programs can help lower my premiums and copays?
  Extra Help is a federal program that reduces Part D premiums and out of pocket drug costs for people with limited income and resources. Medicare Savings Programs are state run and can help pay Part A and Part B costs, and may qualify you automatically for Extra Help. Some states also offer State Pharmaceutical Assistance Programs that add help with drug costs and may count toward your out of pocket limit. Advocates can guide you through checking eligibility and applying.
• How do discounts and coupons work with Medicare and what should I know?
  Federal rules generally do not allow manufacturer copay coupons to be used for drugs that are paid by Medicare or other federal programs. Many manufacturers run separate patient assistance programs that may provide free or discounted medicine if you qualify based on income and other criteria. An advocate can help you find these programs, apply, and coordinate with your prescriber.
• How can an Understood Care advocate help lower my prescription costs?
  An advocate reviews your medication list, checks prices across pharmacies, and guides you to savings programs so you can focus on your health instead of stressing about costs. They look for generics, biosimilars, and preferred formulary options, then help you talk with your prescriber about choices that protect both your health and your budget.
• What help can I get with discounts, assistance programs, and insurance rules?
  Advocates connect you with manufacturer patient assistance programs where allowed, preferred network pharmacy savings, state programs, and Extra Help when you are eligible. They help you understand your plan’s formulary, prior authorization requirements, and step therapy rules. They also support you in requesting exceptions and filing appeals when coverage is denied or limited.
• How do advocates help me stay on track with my treatment plan?
  When medicines are expensive, people often skip or stretch doses, which can lead to worse health and higher costs later. Advocates help by setting up refills, confirming coverage changes, using the monthly payment option when it fits, and troubleshooting denials so you can follow the plan your clinician recommends as closely as possible.
• What practical steps can I take today to manage medication costs?
  You can start by listing every medicine you take, including over the counter products and supplements, and bringing that list to visits. Ask your prescriber whether a generic, biosimilar, or lower tier alternative is right for you. Review your plan’s formulary and ask the pharmacy to confirm the price before you check out. If a drug is not covered or is too expensive, ask your prescriber to request an exception with clear clinical reasons.
• What should I do if I use insulin or take several high cost medications?
  If you use insulin, confirm whether it is billed under Part D or Part B and make sure the thirty five dollar monthly limit is being applied correctly. Consider opting into the Medicare Prescription Payment Plan so your costs are spread across the year. If you take several high cost medicines, it may be especially helpful to work with an advocate who can coordinate with your prescribers and your plan.
• When should I seek more help with medication costs?
  Reach out immediately if you are thinking about skipping doses or stopping a medicine because of cost. Your prescriber may be able to suggest safe alternatives, provide samples, or write a letter 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 and affordable path forward.
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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
• Related Understood Care pages for support
  https://understoodcare.com/care-types/lower-costs-of-medication
  https://understoodcare.com/care-types/application-help
  https://understoodcare.com/healthcare-info/talking-with-your-healthcare-provider

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.