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].

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.

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

• What is this guide about and who is it for?
  This guide is for people who are struggling to afford their medications, especially older adults on Medicare. It explains practical ways to lower prescription costs, how advocates work with your doctor and pharmacy, and how to use insurance rules, programs, and discounts without risking mistakes or gaps in treatment.
• How can an advocate help me with medication costs when I first call?
  On your first call, an advocate collects the exact drug name, dose, how often you take it, your pharmacy, and your plan information. With that, they check if the pharmacy is charging you correctly, compare prices at other pharmacies and through reputable savings programs, look at lower cost but equivalent options, and explain when it is better to use your insurance and when a one time discount price might make more sense.
• Can switching to generics or similar medicines really save money?
  Yes. FDA approved generics must have the same active ingredient, strength, dosage form, route, and clinical effect as the brand name drug. They usually cost less and work the same for most people. An advocate can prepare a simple note for your prescriber that lists comparable generic or lower tier options and coordinate any changes with your pharmacy once your doctor agrees.
• How do Medicare drug plan rules affect what I pay?
  Medicare drug plans use tools like prior authorization, step therapy, and quantity limits. These rules can raise your cost or block coverage if they are not met. An advocate can ask the plan for a coverage determination, request an exception to the formulary or tier when medically appropriate, and help you file an appeal if the plan says no. They also track deadlines so you do not miss your chance to challenge a decision.
• What is Extra Help and how do I know if I qualify?
  Extra Help is a federal program that lowers premiums and reduces copays for people with limited income and resources. Many who qualify are not enrolled. An advocate can screen you, help complete the application, and follow through with Social Security and your plan so you do not have to navigate the process alone.
• What is the Medicare Prescription Payment Plan and how can it help?
  Starting in 2025, you can choose to spread your yearly Part D out of pocket prescription costs into monthly bills from your plan. This does not reduce what you owe overall, but it can make expenses feel more manageable across the year. An advocate can review your situation, explain benefits and tradeoffs, and help you enroll if it fits your budget.
• Are there other assistance programs that can help with medication costs?
  Yes. Depending on your medicines and your state, you may be able to use a State Pharmaceutical Assistance Program that helps with premiums or copays, or manufacturer assistance programs for certain drugs. An advocate can check which programs apply to you, complete applications, and track responses so that forms and faxes do not get lost.
• When should I use a discount price instead of my insurance?
  Discount cards and cash prices are not insurance and usually do not count toward your Medicare out of pocket spending total. If a verified cash or discount price is lower than your copay, it can make sense for a one time fill, especially if you only need a short course. An advocate will compare both options, explain how each affects your yearly spending, and help you decide. Pharmacists are allowed to tell you when a lower cash price is available, but systems do not always show it automatically, so asking matters.
• Can I use manufacturer copay coupons with Medicare?
  Federal guidance does not allow manufacturer copay coupons to be used for medicines that are paid by Medicare Part D. If a coupon seems attractive, an advocate can help you look for compliant alternatives, such as independent charity programs or formulary exceptions, so you do not accidentally break Medicare rules.
• How do advocates coordinate with my doctor and pharmacy?
  Advocates build a current medication list that includes each drug, dose, schedule, prescriber, and pharmacy. With your permission, they share cost saving options and prior authorization details with your care team, send forms for your doctor to sign, and update everyone when changes are made. If you qualify for your plan’s Medication Therapy Management program, they can help you schedule a comprehensive medication review and even join the call if you want support.
• When should I call an advocate right away about medications?
  You should reach out if your copay suddenly increases, a refill is denied, you are told a prior authorization or step therapy is required, you are choosing between a discount price and your insurance and feel unsure, you might qualify for Extra Help or a state program, or you want your doctor to consider a generic or lower tier drug and would like help preparing the request.
• What can I expect from Understood Care when I ask for help with medication costs?
  You can expect a single point of contact who learns your medication list and plan rules, verified price checks across your plan and reputable savings programs, full support for exceptions and appeals, application help for Extra Help and other assistance programs when allowed, coordination with your prescribers to request safe lower cost alternatives, and clear written 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.