The $45,000 Question — What Would You Do If Your Doctor Prescribes A Drug That Costs That Much?

Mary Johnson, editor

Medicare coverage isn’t a set-it once and forget it option. To protect your retirement finances from potentially significant surprise expenses, it’s important to review your drug and health plan options every year. Your health and prescriptions change and so does the coverage of your health and drug plans.

It's an onerous task, but if you haven’t already done so, get free unbiased help and take time NOW to review your options during the Medicare Open Enrollment Period which ends December 7th. Comparing health and drug plans during Medicare Open Enrollment is an essential safeguard. It’s important to learn what your costs will be in 2024 and make any changes now when you can do so. The changes become effective January 1, 2024.

Every area of the country has state health insurance assistance programs ( with Medicare “navigators” ready to help you understand your coverage options, find plans, and help you figure out your best choice. (Or if you are like me and have a condition that requires expensive medications — least worst choice.)  Many of these programs operate through local area agencies on aging.  Medicare counselors can help you figure out what you can expect to pay if you stay in your current plan versus switching to a new plan, and how you might keep your healthcare costs as low as possible or even save money by finding a better deal. The process of comparing plans, knowing what to look for and how to work around Medicare’s often “balky” drug finder software is so much easier when you have someone else to advise you. You can find local contact information here:

In addition to comparing your insurance options annually, it’s also a good time to get an annual check-up and to review your current list of drugs with your doctor. Don’t be shy about asking the price when prescribed a new drug. That price can be heart stopping if your drug plan doesn’t cover it.

Recently my neighbor learned that the new arthritis drug prescribed for her husband would cost about $45,000 a year because it wasn’t covered by his Part D drug plan. My neighbor suffers from rheumatoid arthritis herself and was flummoxed, since she’s been receiving infusion therapy (medication by IV) for years and after the deductible, it’s completely covered by her Medigap plan. Why would her spouse be charged so much more for the new arthritis medication?

The difference has to do with whether the prescription is purchased at a pharmacy and covered under one’s Medicare Part D plan or received as a service (such as an infusion administered at a doctor’s office) which is billed under Medicare Part B (and covered by many Medigap policies).

Although the Inflation Reduction Act legislation gave Medicare authority to negotiate prescription drug prices, a drug needs to be on the market for at least 9 years (among other criteria) before it would even be considered for price negotiation by Medicare. Thus, it could be years before the price of this drug would become more affordable for my neighbor. I urged her to make the doctor aware of problem and to discuss what other drug therapies might be available that would be covered by her husband’s drug plan.

If the average Medicare patient cannot afford $45,000 a year for this medication, and drug plans won’t even cover it, who’s going to pay for it? According to the Congressional Budget Office, the federal government and Medicare are the two largest purchasers of prescription drugs in the United States.

TSCL believes this $45,000 question will come back to bite Members of Congress and the public.  Congress needs to do more to rein in prescription drug costs.

The Inflation Reduction Act added a $2,000 out-of-pocket cap in Part D spending starting in 2025. This new guarantee of an annual out of pocket maximum for Part D beneficiaries was supported by majorities in TSCL surveys. This $45,000 drug, for example, might be considered in 2025 as a more affordable option when the cost of prescriptions for beneficiaries will be capped at $2,000 — assuming at least a few drug plans cover it. But Medicare, taxpayers, and drug plans would be responsible for the rest of the cost, providing an early “stress test” of the financial soundness our new prescription drug price reduction plan.

TSCL believes there’s much more work still to be done to bring down prescription drug costs.