Financial Assistance for Prescription Medications

In the United States, almost 90% of older adults take at least one prescription medication. Depending on what type of insurance you have, your prescription costs can add up quickly, especially if you take multiple medications daily. With the average senior spending $600 per year on prescriptions, it’s important to know what programs are available to assist you in managing these expenses.

This guide provides an overview of options available to seniors who need help paying for their prescription medications. It includes government-managed programs, such as Medicare and Medicaid, as well as prescription assistance programs operated by pharmaceutical companies. You’ll also learn how to save money by using drug discount cards, writing off prescription expenses on your taxes, shopping around for the best deals and purchasing generic drugs instead of brand name.

As of October 2021, nearly 64 million Americans were enrolled in Medicare, an insurance program that provides health coverage to seniors and young adults with disabilities. About 56% of enrollees participated in Original Medicare, a federally run program, while the remaining 44% were enrolled in Medicare Advantage, a private insurance company-run program that allows Medicare beneficiaries to choose from a variety of plans.

Prescriptions are covered by almost all Medicare Advantage Plans; however, unless you purchase supplemental coverage, you are responsible for the full cost of each medication under Original Medicare.

Medicare Part D is a supplemental insurance that can cover the cost of your prescription medications. Unlike Original Medicare, Medicare Part D isn’t managed by the federal government. Instead, private insurance companies offer Part D plans directly to consumers, giving you several options for prescription coverage.

Most insurance companies have their own formularies, which are lists of covered drugs. Every Medicare Part D plan must cover at least two prescription medications in each drug category, making it easier for enrollees to get the medications they need to treat acute illnesses or manage the symptoms of chronic health conditions.

Many plans use a tier system to classify prescription drugs. Medications on the lowest tiers have the lowest copays, while medications on the highest tiers are the most expensive. For example, a generic drug on Tier 1 of a Medicare Part D plan will cost much less than a brand-name medication assigned to Tier 3.

If you enroll in Medicare Part D, you’ll pay a monthly premium, which depends on several factors, such as where you live and which insurance company offers your plan. You’ll also pay a copay for each prescription you fill. Again, the amount of the copay varies based on the terms of your plan. It’s important to note that even though Part D is optional,  there could be late-enrollment penalties down the road if you don’t sign up for a plan when you first become eligible.

Medicare Part D Eligibility and Enrollment

To qualify for Medicare Part D, you must be enrolled in Medicare Part A and/or Medicare Part B. You must also be a U.S. citizen or a lawful resident of the United States. 

When you’re ready to enroll, one of the following options is required:

• Use the Medicare Plan Finder to compare plans and enroll in the plan of your choice
• Fill out a paper enrollment form
• Call 1-800-MEDICARE (633-4227)
• Contact the insurance company directly

The Extra Help program helps eligible participants pay their Medicare Part D premiums, deductibles and other out-of-pocket costs. In 2021, the average Medicare Part D premium was $31.47 per month. This may not seem like much, but Medicare Part B has a monthly premium of $170.10 per month as of 2022. Medicare also has deductibles and coinsurance for some services. These costs add up quickly. If you have limited income and financial resources, you may qualify for Medicare Part D Extra Help. Ultimately, the amount covered depends on whether you’re enrolled in Medicare only or Medicare and another need-based program.

Extra Help Coverage

The table below shows how much you’ll pay out of pocket for your prescriptions if you qualify for Extra Help (program guidelines change periodically). Dual-eligible means that an individual qualifies for both Medicare and Medicaid coverage.

Extra Help Eligibility

To qualify for Extra Help, you need to be enrolled in a Medicare Part D plan. You must also meet certain income and asset requirements. You’ll automatically qualify for Extra Help if any of the following apply to your situation:

• You’re enrolled in both Medicaid and Medicare
• You’re enrolled in both Medicare and the SSI program
• You belong to a Medicare Savings Program that helps pay your Medicare Part B premiums

If you’re automatically enrolled in Extra Help, you’ll receive documentation to present to your insurance company. For example, you may receive a “Notice of Award” if you’re automatically enrolled due to your participation in the SSI program. Keep this documentation in a safe place.

For 2022, the income limit for Extra Help is $20,385 per year for single applicants and $27,465 per year for married couples. The value of your assets can’t exceed $15,510 if you’re single or $30,950 if you’re married. Stocks, bonds, bank accounts, cash and individual retirement accounts are examples of resources that count toward the limit for the Extra Help program.

Enrolling in Extra Help

You can apply for Extra Help by visiting the Social Security website and filling out the online application, scheduling an appointment at your local Social Security office or calling the Social Security Administration at (800) 772-1213. 

Once you’re enrolled, keep an eye out for correspondence regarding the Extra Help program. The Social Security Administration reviews your eligibility periodically to ensure you still meet the enrollment requirements.

Appealing a Denial

If you’ve been turned down for Medicare Extra Help and believe this is a mistake, you can appeal the decision by requesting Form SSA-1021, Appeal of Determination for Extra Help with Medicare Prescription Drug Plan Costs. You can get this form by calling the Social Security Administration at (800) 772-1213, downloading it from the SSA website, contacting your local Social Security office or writing to the following address:

Wilkes-Barre Data Operations Center
P.O. Box 1030
Wilkes-Barre, PA 18767-1030

Medicare Supplement Insurance, also known as Medigap, covers some of the out-of-pocket expenses associated with Original Medicare. For example, if you’re admitted to a hospital, you’ll need to pay a deductible and copayments. Depending on the length of your stay, you may also have to pay coinsurance.

In 2006, the Centers for Medicare & Medicaid Services introduced Medicare Part D to help enrollees pay for their medications. Since then, insurance companies have been prohibited from selling new Medigap plans that cover prescription drugs. Unless you were enrolled in Medigap before 2006 and have a grandfathered plan, you won’t be able to use Medicare Supplement Insurance to cover the cost of your prescriptions.

If you have a grandfathered plan, refer to the documents provided by your insurance company to determine how much you can expect to pay for each prescription you fill.

Prescription coverage is not a required benefit of all Medicaid programs; however, all states offer some type of drug coverage for their Medicaid enrollees. While the federal government contributes to some Medicaid funds, Medicaid is administered at the state level, so your out-of-pocket costs will vary depending on where you live.

For example, Arkansas Medicaid uses a sliding scale to determine how much an enrollee pays for each prescription. The sliding scale is determined by the drug’s cost, with less expensive drugs requiring lower copays.

In Washington, D.C., pregnant women and residents of long-term care facilities don’t have to pay a copay for their prescriptions; otherwise, the copay is $1 per drug. Some states, such as Arizona, California and Connecticut, have no copays at all.

If you’re unsure of the cost of a medication, consult your pharmacist or call your state’s Medicaid hotline.

Medicaid Eligibility

To qualify for Medicaid, you must be a U.S. citizen, lawful permanent resident or other type of non-qualified citizen. You must also live in the state where you’re applying for coverage.

Medicaid also has income and resource limits, which vary by state, with some states setting much higher limits than others. For example, California had a limit of $12,144 per year for a single individual in 2018, while Connecticut had a limit of just $6,276 per year. 

Many states have an asset limit of $2,000 for an individual, but others have limits ranging from $1,600 to $7,560. Arizona has no limit, and California is eliminating its Medicaid asset limit no sooner than January 1, 2024.

Since Medicaid is administered at the state level, you need to contact your state Medicaid agency if you have questions about your eligibility. When you’re ready to apply, visit the agency’s website to download an application or apply online. The National Council on Aging has a directory of Medicaid agencies to make it easier to find information for your state.

Prescription assistance programs (PAP) give consumers access to free or low-cost prescription drugs. These programs are usually managed by pharmaceutical companies, so the eligibility requirements vary based on which company sells the medication you need. Generally, to qualify for a prescription assistance program, you must be without prescription coverage or have extremely limited coverage.

You may also need to provide information about your income and assets, have your doctor fill out a form about your medical condition or provide some other type of documentation to qualify.

Prescription assistance programs are completely separate from Part D, as they’re intended for people who don’t have insurance coverage or whose coverage is extremely limited. If you have Part D, however, you may qualify for a PAP if your Part D plan doesn’t cover the medication you need.

The programs below are managed by some of the largest pharmaceutical companies in the world. Although this list of PAPs isn’t exhaustive, it provides an overview of the eligibility requirements and application instructions for some of the most popular programs.

The Johnson & Johnson Patient Assistance Foundation is a nonprofit organization that distributes donated medications to eligible patients. To qualify for this program, you must meet the following requirements:

• A resident of the United States or a U.S. territory
• No health insurance, or your health insurance doesn’t cover the prescription you need
• You need a prescribed medication that has been donated to the Patient Assistance Foundation by Johnson & Johnson
• You’re being treated as an outpatient by a doctor who’s licensed to practice medicine in the United States

Income limits vary based on which drug you need. As of 2022, the limits range from $40,770 to $81,540 per year for a single individual. Because the limits are so high, you may be able to get help from this program even if you don’t qualify for Medicaid or other need-based programs.

The Johnson & Johnson Patient Assistance Foundation offers over two dozen free medications, including Procrit, Xarelto, Elmiron and Remicade.

How to Apply

For proof of income, make a copy of your 1040 or 1040-SR federal tax return. Alternatively, you can check the box in Section 4 of the application to authorize the Johnson & Johnson Patient Assistance Foundation to perform a credit check to help determine if you’re eligible for the program. Finally, your doctor will need to complete and sign the third page of the application.

When your application is complete, fax it to (888) 526-5168 or mail it to the following address:

Johnson & Johnson Patient Assistance Foundation, Inc.
Patient Assistance Program
P.O. Box 0367
Chesterfield, MO 63006

The Novartis Patient Assistance Foundation provides free Novartis medications to people who have limited or no prescription coverage. To qualify, you must reside in the United States or one of its territories and meet the income requirements outlined below.

How to Apply

If you don’t have these documents or don’t want to provide them, you can authorize the Novartis Patient Assistance Foundation to conduct an electronic income check.
Your doctor will also need to fill out a prescriber application that has questions about your medical history and medication profile. Once the application is complete, fax it to (855) 817-2711 or mail it to the following address:
NPAS
P.O. Box 52029
Phoenix, AZ 85072-2029

Merck’s Patient Assistance Program provides dozens of medications free of charge to individuals with very limited or no prescription coverage. Keytruda, Prevymis and Isentress are among the covered medications. Merck’s PAP also provides free adult vaccines, including Pneumovax 23, to eligible patients. 

To qualify for the Merck PAP, you must be a U.S. resident and have a prescription for a Merck product. The prescription must be from a licensed health care professional in the United States. Merck’s PAP has income limits that vary based on which drug you need. For example, an individual who needs Prevymis qualifies with an income of no more than $67,950 per year, while someone who needs Dificid has a limit of $54,360 per year.

How to Apply

To see if you qualify , go to MerckHelps.com and select your medication from the list on the right side of the page.

If you’re eligible, fill out the Merck Patient Assistance Program Enrollment Form. You’ll need to have your physician complete the second page of the application before you submit it. When the application is complete, send it to the following address:

Merck Patient Assistance Program
P.O. Box 690
Horsham, PA 19044-9979

AbbVie offers several patient assistance programs to help people who don’t have prescription coverage get their medications. You must meet the following requirements to qualify for assistance:

• Limited or no insurance coverage
• Be prescribed an AbbVie medication that’s included in the PAP
• Reside in the United States
• Be in the care of a doctor licensed to practice in the United States
• Demonstrate financial need

Income limits for myAbbVie programs are as follows:

How to Apply

To determine if your medication is available through myAbbVie Assist, visit the AbbVie website and browse the list of products. Click on the name of your medication to get information about the program and download an application. 

AbbVie has separate applications for different medications, so double-check that you downloaded the correct one before filling it out.

Fax your completed application to (866) 898-1473 or mail it to the following address:

myAbbVie Assist
P.O. Box 270
Somerville, NJ 08876

The Bristol-Myers Squibb Patient Assistance Foundation is a nonprofit organization that helps eligible patients get brand-name medications made by Bristol-Myers Squibb. Covered medications include Eliquis, Orencia and Opdivo. To qualify for assistance from the BMS Patient Assistance Foundation, you must meet the following requirements:

• Reside in the United States, Puerto Rico or the U.S. Virgin Islands
• Be treated as an outpatient by a doctor licensed to practice medicine in the United States
• You need Orencia or Eliquis and have an annual household income of $40,770 for an individual or $54,930 for a two-person household
• You exceed the income limits above and need a BMS medication for a kidney transplant, ulcerative colitis, cancer or multiple sclerosis

How to Apply

First, make sure your medication is included in the program. The BMS Patient Assistance Foundation has a list of eligible medications on its website. If it’s included, visit the application page, use the dropdown menu to select your medication and click “Download the application.” Alternatively, you can call (800) 736-0003 and ask to have an application faxed or mailed to you.

When filling out the application, don’t leave any blank lines. If something doesn’t apply to you, write N/A. You’ll also need to attach supporting documentation, such as a copy of your tax return, and have your doctor fill in information about your medical treatment. Send the completed form to the fax number or mailing address listed on the application.

Sanofi Patient Assistance Connection provides free medications to patients who meet the program’s eligibility requirements. As of 2022, Sanofi PAC covers 18 prescription drugs, including Synvisc, Priftin, Lovenox and Apidra. To qualify, you must be a resident of the United States or one of its territories and have a household income at or below 400% of the FPL. As of 2022, the income limits for all states, except Alaska and Hawaii, are as follows:

The table below displays the income limits for Alaska and Hawaii.

How to Apply

Sanofi Patient Connection
P.O. Box 222138
Charlotte, NC 28222-2138

image:

If you don’t qualify for any of the options above, there are other ways to make your prescription costs more manageable. You may also be able to take a tax deduction for unreimbursed prescription expenses, putting more money back in your pocket during tax season.

Drug discount cards, also known as prescription drug coupons, work just like the coupons you use at the grocery store. When you go to the pharmacy, you present the card to the cashier and receive a discount on the retail price. In most cases, you can’t combine drug discounts with commercial insurance coverage, but this is a good option if your insurance doesn’t cover a specific drug or if the copay for the medication is higher than using the coupon and paying out of pocket.

Drug discount cards are often designed to look like insurance cards, which makes it easier for pharmacies to apply them to each order. You may see a discount card with a group number, ID number, processor control number (PCN) or bank identification number (BIN).

GoodRx is one of the most popular sites for prescription drug discounts. When you use GoodRx, you can search by drug name and ZIP Code to find the best discounts in your area. You can also print a coupon directly from the site.

Prices vary based on several factors, including where you live and which pharmacy you use. For example, a search for Lipitor in ZIP Code 18702 shows that someone using a GoodRx coupon can get a 30-day supply of the drug for just $3.76, a savings of 79% off the average retail price. This is just one example of how you can use GoodRx to save money.  

If you itemize your tax deductions, you may be able to deduct the cost of unreimbursed prescription costs and other medical expenses on your federal tax return. The deduction is only available to taxpayers whose unreimbursed medical expenses exceed 7.5% of their adjusted gross incomes. If your adjusted gross income is $50,000, for example, you’d only be able to deduct your unreimbursed medical expenses if they exceed $3,750.

Talk with a tax professional before itemizing your deductions; although it’s a good move for some taxpayers, others would benefit more from taking the standard deduction.

Some states allow taxpayers to deduct their unreimbursed medical expenses even if they don’t qualify for the federal deduction. For example, New Mexico offers a refundable medical expense credit for residents aged 65 and older. Younger New Mexico residents can also deduct a certain percentage of their unreimbursed medical expenses on their annual state tax returns.

Since each state has its own rules regarding tax deductions and credits, check with your state revenue agency, a certified public accountant or an experienced tax preparer to determine if you qualify for any tax savings associated with your prescription costs.

Many brand-name drugs have generic equivalents containing the same active ingredients, giving you another opportunity to save money on your prescriptions. Manufacturers must meet strict quality and safety standards when producing generic medications, making them just as safe as their brand-name counterparts. Generic drugs also have the lowest copays if you have Medicare Part D or another type of prescription coverage, making them even more affordable.

Most drugs have a generic version available, but if your medication is still under patent protection, you may need to continue purchasing the brand-name version until a generic one enters the market. You may also need to purchase a brand-name drug if you’re allergic to one of the inactive ingredients in the generic version.

Walmart offers a 30-day supply of many common medications for just under $5. Medications on the $4 list are used to treat high cholesterol, diabetes, heart disease, high blood pressure and other chronic diseases. The list also includes vitamins, minerals and medications used for family planning.

In January 2022, Mark Cuban launched his Cost Plus Drug Company to help consumers save money on their medications. The price of each drug is based on the cost to produce it, along with a 15% markup and a $3 fee for the labor required to fill the prescription. The common migraine medicine Sumatriptan Succinate, for example, has a retail price of $234 for a 30-day supply. Mark Cuban Cost Plus Drug Company charges $9 for the same drug in the same quantity.

If you don’t have prescription coverage, or if you can’t afford your copays, you may be able to save money by ordering from this company or getting a generic from another pharmacy.

You might be able to save money on your prescriptions if you use a mail-order pharmacy instead of picking them up at a retail location. Mail-order pharmacies typically serve specific insurance plans, allowing those plans to purchase drugs in bulk. Buying in bulk reduces the overall cost of the drugs, making it less expensive for consumers to get their prescriptions from a mail-order pharmacy instead of a retail one.

Although many people save money with mail orders, it’s not the cheapest option for everyone. If you’re thinking about making the switch, contact your insurance company to find out how much you can expect to pay for your medications if you get them via mail order.

Below are comprehensive, downloadable guides explaining the resources available to help pay for prescription medications in every state. Read your state’s guide to learn what options may be available to you.