Benefit Bulletin: April/May 2021

Benefit Bulletin: April/May 2021

What To Do When The Doctor Recommends A Budget Busting Drug

Rick Delaney, Chairman of the Board

Recently we received the following:  My doctor wants to put me on a new medication for my rheumatoid arthritis, but my Medicare Part D plan says my cost would be $1,000 per month.  The doctor says that there are pharmacy assistance programs to help with the cost, but the group that runs the program for this drug isn’t taking any new patients.  What am I supposed to do?  I can’t afford $1,000 per month for one prescription!

One would think doctors should be familiar with the cost of the medications they prescribe, but with every Part D insurance plan covering different drugs, and at different co-pays, that leaves it up to you to speak up when cost is a factor.  Don’t worry, doctors are very used to hearing this from patients.  Here are a number of things you can try:

  1. Call your drug plan and learn whether the prescription drug would cost less from a different pharmacy.  Learn if the cost would be lower from a different retail pharmacy or mail-order.  Sometimes high drug quotes are due to using a non-preferred pharmacy, and your co-pay may be more affordable at the drug store down the road.
  2. Immediately tell your doctor about the cost, and the problem with the pharmacy assistance program, and ask if your doctor has free samples of the medication, or if there’s an alternative medication that you can use.  You can use the Formulary Browser in order to see the medications on your plan’s drug list.  If you have a smart phone, you may want to bookmark this browser to have on hand when you visit the doctor again.
  3. If you cannot find an alternative medication, ask your Medicare Part D plan for a formulary exemption.  This would ensure that your non-formulary medication is covered by your 2021 Medicare plan.  You can learn more about requesting a formulary (or tier) exemption using the Medicare Interactive tool from the Medicare Rights Center.
  4. Contact a State Health Insurance Program Counsellor (SHIP).  You can get free one-on-one counseling from SHIP Medicare counselors who may be able to help you locate an alternate pharmacy benefit program.  These counselors will also be able to help you enroll in Medicare Extra Help, which is the Medicare program that covers most of the premium and out of pocket costs of prescription drugs for people with low incomes.
  5. Contact your Members of Congress.  Medicare prescription drug coverage was enacted for a reason — to protect Medicare recipients from the high out-of-pocket costs of prescription drugs.  Obviously, Medicare is having trouble keeping its promise.  Concisely describe your situation in an email and explain the steps you have taken.  Ask the constituent services aide if they can help link you to programs and agencies in your area that can help.  And ask that he or she support legislation that would cut your prescription drug costs.  Time and again we have been told these constituent services aides have been able to get the ball rolling in the right direction when nobody else could.


Every year, more than one out of five older Americans find themselves unable to afford one or more prescriptions that their doctor says they need.  TSCL believes it is long past time to enact legislation to allow Medicare to negotiate drug prices, and to lower the out-of-pocket costs of beneficiaries.