The cost for my medications​

Question from Ella: I take Eliquis and have an Advantage Plan. This year I don’t have a deductible and my cost for Eliquis is just $45 for a month’s supply. In 2027 my plan is going to have $700 deductible on that medication and other Tier 3 drugs. I also will no longer have a $45 co-pay and my understanding, if I’m reading it correctly, is I will be responsible for 25% of that drug’s cost after the deductible has been met instead of $45. My overall expenses are going to be much higher and hard for me to afford. What are my options? 

Answer: I wish I could advise Ella to simply find another Advantage Plan that has the same drug costs in 2027 that she does in 2026. But, unfortunately, in 2027 there are almost none left that don’t have a deductible for Tiers 3 drugs and also a flat co-pay like she has now. Almost all have a $500 to $700 deductible that must be paid first. Once the deductible has been met, the cost for a 30-day supply is likely to be 20% to 25% of the retail cost. 

In Western Pennsylvania, the only Advantage Plans that don’t have a deductible and still provide drugs at a flat co-pay have premiums that run around $100 to $150 per month more and don’t come with any dental coverage, so it doesn’t make sense for many people to make that move. There may be a couple plans, like we have available here in Pennsylvania, that don’t have a deductible, but those have a limited doctor and hospital network and may not be an option for everyone.  

The $700 deductible is harsh and unaffordable for many seniors, although 20% or 25% of the retail for Eliquis isn’t going to be terrible because it, along with many other medications, are included in the Medicare Drug Price Negotiation Program. Eliquis now has a retail cost of $255 per month, meaning 20% is $51 and 25% is $64. But still, due to the new structure of the Part D portion of her Advantage Plan, Ella may be forced to pay $850 more for Eliquis in 2027 than she did this year unless she can find a plan that doesn’t have a deductible. 

If she can’t, what almost every single one of our clients who take Eliquis are currently doing is buying it from a Canadian pharmacy. It’s available in generic form from Canada and the cost is as little as $60 plus shipping for a 90-day supply! That’s just $240 for the entire year. If the Canadian option is available to Ella next year, that’s my recommendation. 

The only issue with Canadian Pharmacies is there is a proposed US Customs ban on shipments of these medications that’s now set to go into effect January 20^th. That ban was originally going to begin this month but was delayed until after the midterm elections. 

It’s estimated that 3 million people in the US buy their drugs from Canada. Seniors who are on a fixed income can’t afford to spend $1,000 to $2,000 more on a single medication next year, which is what many are facing if the ban goes into effect. I strongly urge all seniors to call their Senators and House Reps who have ties to Washington DC. Let them know they need to permanently end this ban on Canadian drugs, not just postpone it, that you’re paying attention, and it may influence the way you vote. 

There are many medications other than Eliquis available from Canada that are hundreds or thousands of dollars less per year than the cost of using Part D drug coverage in the US. But many, such as Ozempic and Monjuaro, the most common drugs prescribed for diabetes, aren’t. Those who take Monjuaro will be forced to pay around $2,400, the new out of pocket limit for covered drugs, for it and other expensive brand name medications next year. 

So, what do those folks do who can’t get drugs cheaper in Canada? 

You can work with your pharmacist and physician to find less expensive generic alternatives. However, that’s not always possible. The GLP1 drugs I just mentioned work so well for people with diabetes, there’s likely no alternative that will lower A1C and help with weight loss, so an alternative just isn’t possible. 

In Pennsylvania, we’re blessed that our lottery proceeds are used to help seniors by eliminating their drug deductible and ensuring they never pay more than $15 for a month’s supply for any prescription medication. This program is called PACENET. 

Several other states operate State Pharmaceutical Assistance Programs (SPAPs) to assist seniors with medication expenses, utilizing funding sources that may combine lottery revenues alongside tobacco settlements, taxes, or general state funds. Examples include states such as New Jersey (PAAD and Senior Gold), New York (EPIC), Vermont (VPharm), Wisconsin (SeniorCare), Massachusetts (Prescription Advantage), and several others including Maryland, Maine, Rhode Island, Missouri, Montana, Indiana, and Delaware. So, if you live in one of those states, find your program and look into them. However, these programs have income limits and not everyone will qualify. We have lots of clients just over the income limits who are going to struggle with drug costs next year. 

There are still a select few medications that the drug manufacturers themselves provide people at no cost and the income limits to qualify are generally higher than the PACENET and SPAPs. These are called Patient Assistance Programs (PAPs). Just Google the name of the expensive drug you’re taking and then type Patient Assistance Program behind it. That’s the easiest way to find out if that drug has a PAP. But again, and unfortunately, since the new cap on out-of-pocket drug costs went into effect in 2025, there are very few meds that the drug makers are helping people with. This is very disappointing considering how profitable these companies are, mostly on the back of US taxpayers since the retail costs of our brand name medications are generally 300% to 1,000% higher than any other nation.

If you still can’t avoid paying more for meds, the next best option is to find savings elsewhere to free up money to cover the additional costs. The most likely source is changing Supplements (Medigap) letter plans. Plans C, F, and G are overpriced and antiquated. A move to Plan N or Innovative G can save thousands of dollars per year and we’re doing that every day for clients! 

Those who are on Advantage Plans, like Ella, also may be paying too much premium or exposing themselves to out-of-pocket medical costs they could avoid by changing plans or companies. 

One of the biggest and most common mistakes we see people making is remaining on their Supplement or Advantage Plan year after year after year, not shopping or comparing plans, allowing their familiarity and fear of change to influence their decision. Insurance companies count on that fear and anxiety, and it can cost you or your family members tons of money. Make sure you’re comparing plans side by side during the Annual Election Period that’s going on right now! 

With questions about this topic or any other related to Medicare, or to make an appointment for a no cost consultation with myself or another of the experienced agents at The Health Insurance Store, give us a call, 724-603-3403 or feel free to email me personally, Aaron@GetYourBestPlan.com.