Rising prescription medication costs continue to be one of the biggest complaints that we hear from our clients and other Medicare consumers. So, today we'll break down how you may be able to spend less and save money on prescription medications. 

But before we start, my name is Cameron Giardini, and together with my co-host Joanne Giardini Russell, we operate Giardini Medicare, which is an independent insurance agency based out of Southeast Michigan. Although we are based out of Michigan, we do work virtually over the phone to directly help consumers in about 13 different states to find the right Medicare coverage for them. However, if we do not work in your state, we will still connect you to another trusted independent agent that will be able to help you find the right coverage that you want. And of course, even if you choose not to work with us, we know that the information in today's podcast will help you with a successful stress-free transition to Medicare. So first we'll have Joanne start with an overview of today's episode. 

Today we'll talk about how using a good broker can help you when it comes to expensive prescriptions. We're going to teach you about how checking your prescription coverage with your Part D or Medicare Advantage plans can be to your benefit. We're going to talk about government assistance, talk about things like a low-income subsidy, and extra help. What does that really mean? We'll discuss prescription savings with online discounts and coupons. We'll discuss patient assistance programs, and we're going to talk about potential foreign sources of medications. 

First, as you said, we're going to talk about how a broker like ourselves or another broker can hopefully help you with expensive prescriptions. Insurance companies themselves, are unlikely to assist you with alternative prescription saving sources. If you call your insurance company, whether it's your Medicare Advantage plan, or your Part D plan, they're just going to tell you, “Your medication is this tier, it's tier one, tier two, whatever it might be, tier five.” They might suggest a couple of generic alternatives that they cover, but they're not going to take the time to look at outside sources to see how you might be able to save some money on prescriptions. So, we'll talk about that. And again, that's where a broker can come into play. Just like everything else we do, our services are completely free to you. 

 Everything that we help you with as far as expensive prescription savings or claims issues, that's no cost to you. Our service team solely exists to help people with issues like this. We really get absolutely no benefit from you spending money on prescriptions. Our only goal is to assist you, help you save money, and to keep you happy as a long-term client. One of the first things we consider when it comes to hopefully saving you some money on prescriptions is do you qualify for the government assistance program, which is known as a low-income subsidy or extra help. The low-income subsidy, also known as LIS, Medicare defines as a federal program that helps people with limited income and resources pay for Medicare drug coverage, premiums, deductibles, co-insurance, and other costs. So how can you qualify for this program? 

 For this episode, we're just going to give a brief overview. There is a little bit more to it, but as far as the income resource limits go, here are some of the guidelines based on CMS’s data. Your monthly income can be up to $1,843 per month for individuals and $2,485 for couples. Now, these income qualifications are a little bit different in Hawaii, Alaska, and DC, so just make sure you look at those if you live in any of those states or areas. And then lastly, go along with income, your resources also must meet certain thresholds to qualify for this low-income subsidy. Social Security states that your combined savings investments and real estate are not worth more than $33,240 if you're married and living with your spouse, or $16,660 if you are not currently married or not living with your spouse. So, if you think you might meet these qualifications, how do you apply? 

 Well, the easiest way is to complete the online application on Social Security’s website. We will link to that application in the show notes for this episode. However, just know that if you have Medicare and supplemental security income or also known as SSI, or if you have Medicare and Medicaid, you do not have to fill out an application for a low-income subsidy because you are automatically eligible and you will automatically be enrolled into the extra help program. So, Joanne can talk a little bit more about extra help and we'll move on to the next topic, 

Okay, so what are the benefits of LIS? Number one, it waives the Part D penalty. So, at the point that you qualify for a low-income subsidy, they'll waive a prior Part D penalty should you have received one. You also have an added special enrollment period where you can change prescription drug coverage. There's a huge benefit compared to people that don't have access to this program. You're going to get lower plan premiums, deductibles, copays, and coinsurance. Now, there are a couple of different levels. As mentioned, you can either be full LIS and in this case, you're going to have zero monthly premium for the benchmark plans. You're going to pay a zero deductible. You'll be paying $4.15 per generic medication and $10.35 for each brand of medication. You won't be subjected to the donut hole, which is a different topic, and you're going to pay zero during the catastrophic coverage phase of the prescription program. 

Joanne mentioned zero premium for those benchmark plans. Just know that not every single plan is known as a benchmark plan. There are usually about 8 to 10, maybe 12 plans in each area as far as Part D goes that are benchmark plans. So, it's not zero for every plan, but just reach out if you have questions or talk to a broker that can help you with that.

 You'll be able to find one if you have full LIS. Then again, if you don't have access to full LIS, you may get partial LIS. So, you're going to have lesser savings that we are going to link in the show notes. We won't break down each one of those. And here's a tip, if you want to see the actual costs related to your medication, your zip code, and things like that, what are benchmark plans in your area? Go to medicare.gov. When you get into the system, it's going to ask, do you qualify for any of these programs? You would select yes that you get extra help, and then walk through that. That's a good way for you to see the moving parts and exactly what you'd be paying. Now I'll talk about some upcoming changes to the low-income subsidy program due to the Inflation Reduction Act. According to Kaiser Family Foundation, beginning in 2024, individuals that meet the criteria for partial LIS will instead be eligible for full LIS, which is a huge enhancement. 

Now, you may be thinking though, that sounds great, but I don't meet those thresholds or my income or resources are higher. So, what happens next? The next thing we would suggest, of course, is to look at your current coverage. Look at your current plan or even think about what potential prescription coverages you could have in the future. If you're listening to this episode, you probably already have, or you're looking to enroll in some type of prescription Medicare coverage, which is probably either through part D or through Medicare Advantage Plans. So, to do this, just go to medicare.gov and you can see the cost estimates for your current prescriptions for the plan you are currently enrolled in, or one that you are possibly thinking of signing up for. Just make sure you're currently enrolled in a plan or enrolling in a plan that fits your unique medications as well as possible. 

 Now, keep in mind Medicare.gov usually defaults to sort plans by the lowest overall cost, which includes your premium and your prescription costs. Also, keep in mind that Part D plans and Medicare Advantage plans can only be changed during certain periods of the year. This tip is going to work, I would say better or worse, depending on the time of year to see if you can make a change. Now, if you can't make a change, worry about maximizing your current coverage. So, make sure you're using a preferred pharmacy. If possible, check to see if mail order will provide any savings for you if you currently have a prescription that is causing you trouble with your plan. You can also consider generic medication alternatives with your doctor that are better covered by your plan. Just know that not every generic medication is cheap medication. 

 You can still have a generic version of a medication that's a specialty medication and it's still very costly when you look at the actual pricing. Lastly, when it comes to your current coverage or potential coverage, you can also consider a formulary exception or a tier exception with your plan. A formulary, just really quick, that's the documented long list of prescriptions that are covered by your plan. It talks about how they're covered, what tier, is there any restrictions to them. So just keep in mind that's what a formulary is. And a formulary exception is when you can request to have a non-covered medication be covered by your plan. Now, this isn't automatic. Your physician would have to document the necessity of the medication. You can also even try tier exception where you can try to lower the tier of medication if it's already covered by your plan. 

 An example of this is if you have a tier 3 medication and it's a generic medication and you think it might be better off being at tier 2, or that could help you save money. Now your provider, again, must document the necessity of that medication compared to preferred ones. That was the steps you can take if you want to look at your current coverage or think about other plans. But beyond that, let's talk about what you can do outside of Part D, outside of Medicare. Let's talk about ways you can hopefully save some money on prescriptions. 

As I talk about this next segment, I just want to bring up something too that we didn't really talk about. But when Cameron said, rely on your broker, ask some of these questions for tips and resources, and do it before you go to the pharmacy. I think of this because I got an email this morning and it was from someone taking two tier 1's that are very, very inexpensive. He's doing something wrong with his plan and he is telling me he just paid $43 for each one. It should have been zero or $3, something like that. So don't do it after the fact because it’s harder to fix things after the fact. 

Or if something feels wrong, take a moment, give your broker or us a call if you're our clients and then we can hopefully help you through it before you pay that money and must go through refunds or backtracking in any way. 

That's the problem here because my next thing with him would've been, okay, go to GoodRx, but now it's too late. But in this case, I just think he went to the probably wrong pharmacy. Anyway, we'll move into saving things with online coupons and other discount programs. So, there's a whole bunch of these places. Keep in mind with these outside sources online like GoodRx, when you're purchasing your prescriptions through these programs, what you are paying out of pocket is outside of your part D prescription drug plan. They're not going to count toward the deductible. We get that question a lot!

 You might want to reconsider, the pricing if you're only going to get minor savings, maybe you do want it to go towards your deductible, you're going to have to do a little bit of assessing on your own with that. These online coupons and discounts cannot be combined also with your Medicare prescription drug coverage. So, it is one or the other. Do not walk in with both cards and expect double coverage. Here are some potential saving sources… There are online places such as GoodRx, SingleCare, Clever Rx, Blink Health, and several others. These are just the ones that we frequently hand out to our clients and tell them about. There's cost plus drugs. I think that one's phenomenal. It's Mark Cuban's company. They're doing a great job bringing down quite a few prescription prices. Amazon Pharmacy, they've got something called the RX Pass. And if you're an Amazon Prime member, you can get eligible generic medications for a flat $5 monthly fee. You can have an unlimited number of covered medications for that five, $5 fee. So that's pretty slick. 

Obviously, there are many more online coupons out there and savings programs, but as Joanne said, those are some of the more popular ones that we run into. Just a note about cost plus drugs versus some of those online savings coupons. The reason I tend to favor cost-plus drugs if the medication is a good price is that their prices are generally set. They charge you an added fee on top of the actual cost of medication. But GoodRx a lot of times is an estimate. So, when you go to the pharmacy, you might have a coupon that says this medication is $5 and they actually run it through the system, and it might be $20. I know I had that recently. I got a prescription, and it said $17 on the coupon, but it ended up being $40 at CVS. They're a lot more flexible with those prices versus somebody like cost-plus drugs or other sources out there. 

But now shifting away from the coupon side of things, let's talk about the actual pharmaceutical patient assistance program. So, what are these? Well, pharmaceutical manufacturers, might directly sponsor patient assistance programs to help with the cost of prescriptions that they make. These are programs directly from the drug manufacturer. And these programs, again, are separate from your Medicare prescription coverage. So just like Joanne said, with coupons, what you pay for your medications doesn't count towards your part D true out-of-pocket cost. Now, a good resource to find these assistance programs that we use is called needymeds.org. It's our preferred method because all you do is type in the name of your prescription, and it will show you all the different patient assistance programs that are available to you. 

 Now again, these are the ones that might be available to you. You have to still qualify for them, which we'll talk about. Just know that there are Needy meds, and then also RX Assist is another website that is an option for that. Now, there are services out there that charge a fee to help with these assistance applications. There's simple fill and Prescription Hope. Those are two that I can think of off the top of my head, and these can work as options. They're okay, but independent brokers like ourselves can help you file these assistance applications, or we can help guide you through the process without charging you a fee. So, a lot of times those programs will help you with the application, and help you try to see if you qualify. And then if you do qualify, you must pay them per each medication you get through the program. 

 So, they're just helping you with a free program and they add that charge on top of it. Every assistance program keep in mind, is different. Some are not available for those with Medicare. I would say a decent chunk is not. This is very common with copay cards. I can think of Eliquis off the top of my head as well, where you get a copay card where it might be $5 or $10 and then suddenly you start Medicare, and you realize that's no longer the case. Many of these programs are based on income. So, look at the programs available for your medications and apply for whatever seems possible. Reach out to them, just ask, if qualifying based on everything that they ask you. And then there are actual state pharmaceutical assistance programs. According to the Medicare Rights Center, many states offer State Pharmaceutical Assistance Programs to help residents pay for prescription drugs. 

 We will provide a link to these states in the show notes for this episode to see if you might be in one of those states. I know New York has one called “Epic”, I'm not that familiar with it, but it had to do with income. Just check on your state to see if they also have assistance programs. Joanne can talk about one that's a little bit outside of the box as far as medication sources. I guess it's probably more common for us since we live right near Canada, being in Michigan, but she can take it away. 

Yeah, we're talking foreign medication sources, and this is a little bit of a legal gray area if you will. We hear both sides of the story. More and more states and governments are really pushing to try and import medications from other countries at lower prices. So, we're just saying we'll expose you to the concept, but use this method at your own risk. Many of these sources are online Canadian pharmacies, but medications can be sourced from multiple countries around the world. There's Turkey, Israel, lots, and lots of places. We even have a lot of our customers who are foreign residents of other countries, and we always hear from them about how inexpensive medications can be in their countries. Remember that you're going to need a prescription for these medications. 

 And we're also going to recommend along those lines that you consult with your own doctor. If you want to consider these savings methods, there is a place called pharmacychecker.com. We'll put that in the show notes, but it can help you compare the prices and many of these online foreign pharmacies that source the medications from outside of the United States. Do your own price searches for Canadian pharmacies. We do recommend that if you go this route you consider a CIPA-certified pharmacy, which is the Canadian International Pharmacy Association. Go to cipa.com to learn more if you'd like to go that route.

There's a lot more to it when it comes to foreign medications, but that's just an overview. Take it how you will and see what might work for you. Another option that we just want to put out there, is 340B pharmacies. They are not that prevalent, but it depends on where you live. But don't get too excited thinking this may be an easy solution for you. So, this method, again, comes down to your location. And according to 340Bhealth.org, this 340B program exists because it requires drug manufacturers that participate in Medicare and Medicaid to sell discount medications to eligible hospitals. 

 These eligible hospitals and facilities are also called “covered entities”. If you want to try to use the 340B program to your advantage, you do need to get care from a provider or be referred by a provider that is part of that covered entity. These are commonly federally qualified health centers. This may require you to change your physician and care to a new location. You must establish care at one of these covered entities. Now, many 340B benefits, are also income based. They might have high-income thresholds though, so it might be worth considering even with higher income. It's also important just to check with the facility to see if you can qualify. We'll link to a website to find these federally qualified health centers in your area. 

 So, if you find one that's within a reasonable distance from your zip code, feel free to check it out. Again, it's a 340 B program. If you're in a more rural area with a lower income population that is easier to serve with these covered entities, that's where you might run into more success with a 340 B pharmacy. I just know we've looked in Metro Detroit and it's hit or miss, but that's pretty much all the different ways that we recommend saving money on prescriptions in unique ways outside of your Part D or Medicare Advantage coverage. But we'll finish this off with Joanne telling us about some upcoming changes to Medicare itself as far as their prescription coverage. 

All right, these changes are being implemented due to the Inflation Reduction Act that was passed in 2022. A few things that are going to change are the catastrophic coverage portion of a prescription drug plan will be $0 starting in 2024. It will also bring a $2,000 cap on prescriptions in 2025 with the ability to spread the payments out throughout the year. Those people that are currently eligible for partial LIS are eligible for full low-income subsidy benefits beginning in 2024. Medicare will also begin negotiating the prices of 10 of the most expensive Part D medications beginning in 2026, and they'll begin negotiating some part B medications in 2028. Please go listen to our episode from August 14th, 2022, to learn more details about all the changes that are going to happen due to the Inflation Reduction Act.

Whether you choose Medicare Advantage or Part D coverage, those plans are just beginning when it comes to trying to save money on more expensive medications. Hopefully some of the information we provided in this episode can help you find additional potential cost savings for any expensive medications that you may be prescribed while on Medicare. As always, please leave us a review on your podcast app and subscribe so you can listen to future episodes. You can also find more content from us by going to YouTube and searching “Giardini Medicare”. Lastly, if you want to give us any feedback or questions, you can send us an email directly to info@gmedicareteam.com. Thank you and have a wonderful day.