When the pharmacy tells you what a prescription comes to and the money for it is not there this month, there are public programs that may lower what you pay, and clinics that set their fees by income. If you have no coverage at all, you can apply for Medicaid and CHIP at any time of year, so you can send an application this month.
A program that lowers what you pay, and how to find out if you are in one
Which program can lower what you pay turns on the coverage you hold, and you find out whether you are in one by applying, or, for some people with Medicare, from a notice in the mail.
| Coverage you hold | What may lower the cost | Where you apply or find out |
|---|---|---|
| Medicare, with full-benefit Medicaid, Supplemental Security Income, or state help paying your Part B premiums | Extra Help, which comes automatically | A notice in the mail |
| Medicare without any of those | Extra Help, and a Medicare Savings Program for other Medicare costs, started by the same application | Social Security's Extra Help application, with free help from your local SHIP |
| No coverage | Medicaid or CHIP, or savings on a Marketplace plan | A Marketplace application, or your state Medicaid agency |
| A plan you buy through the Marketplace | Savings worked out from the income you expect in the year of coverage | A Marketplace application |
| No health plan you can afford, and no Medicaid or CHIP | A community health center, which sets fees by income | The Find a Health Center tool |
For people with Medicare, the program is Extra Help, which helps people with limited income and resources pay their Medicare drug coverage (Part D) costs, including coinsurance, and it enrolls you in a drug plan if you do not have one. You get it automatically if you get full-benefit Medicaid coverage, help from your state paying your Part B premiums through a Medicare Savings Program, or Supplemental Security Income payments from Social Security, and a notice in the mail tells you things like how much you will pay. Everyone else applies to Social Security, and a local State Health Insurance Assistance Program, or SHIP, gives free help applying; you can reach both through Medicare's Talk to someone page.
That application can start a second one. A Medicare Savings Program is a state program that helps with other Medicare costs, and Social Security sends your information to your state to begin an application for it unless you say no on the Extra Help form. In most cases you need income and resources below a limit to qualify for Extra Help, and those limits may go up each year, so check this year's income and resource limits, or ask your SHIP, before deciding you are over them. If you were turned down before, you can reapply any time your income and resources change.
Extra Help is not available in Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands or American Samoa. Other programs help people with limited income and resources in those areas, and they vary from one area to the next, so call your State Medical Assistance (Medicaid) office to learn which exist where you live.
If you already get Extra Help and the price at the counter looks wrong, contact your drug plan, which may ask for proof that you get it, and tell the plan how many days of medicine you have left: your plan and Medicare will try to fix the problem before you run out. Call 1-800-MEDICARE (1-800-633-4227), or 1-877-486-2048 on TTY, to learn your level of Extra Help and get help having the cost corrected with the plan.
Without Medicare, look first at Medicaid and CHIP: they provide free or low-cost health coverage to eligible low-income adults, families and children, pregnant women, the elderly and people with disabilities. Income levels, coverage and costs may differ from state to state, and some states have expanded Medicaid to cover all people with household incomes below a certain level while others have not. For immigrants, full Medicaid or CHIP coverage now depends on status: after a law change, only Lawful Permanent Residents (Green Card holders), Cuban or Haitian entrants and Compact of Free Association (COFA) migrants are eligible for it, though depending on the state, lawfully residing pregnant women and children may be eligible too.
An income that looks too high on paper is still worth an application. Each state has coverage options that consider income, household size, family status such as pregnancy or caring for young children, disability, age and other factors, and you might qualify for your state's program even when you do not expect to on income, especially if you have children, are pregnant or have a disability. Apply through the Marketplace, which sends your information to your state agency if it looks like anyone in your household qualifies, or directly through your state Medicaid agency. Medicaid may also be able to help pay for medical care from the last 3 months, even if you were not enrolled when you got it, depending on your family's income and medical expenses at the time. For questions about a Marketplace application, call HealthCare.gov at 1-800-318-2596; for one made directly to your state, contact your state Medicaid agency, and selecting your state on HealthCare.gov's Medicaid page gives its contact information.
If you buy your own plan through the Marketplace and your income has dropped, the savings on a Marketplace plan are based on your income estimate for the year you want coverage, not last year's. When you work out the household for that estimate, count yourself, your spouse if you are married, and everyone you will claim as a tax dependent, including anyone who does not need coverage. The exact plan prices and savings come when you fill out a Marketplace application.
For people with Medicare, two more places to ask are the company that makes the drug, which may offer help paying for it, and your state, which may offer help with drug costs. You can find your state's office through Medicare's Talk to someone page too.
If your health insurer refused to pay for the prescription, you have the right to appeal the company's decision and have it reviewed by a third party (see Appealing a health plan that refused to cover your prescription).
Where you can be seen for less
You can be seen for less at a community health center. Every health center adjusts its fees to income and family size, and must serve everyone, even people who cannot pay, so it is not only for people without a job or a home. Health centers are local clinics for medical, dental, mental health, substance use and other health care needs, in both urban and rural areas, and if no health plan is within your means and you do not qualify for Medicaid or CHIP, one in your area can give you low-cost health care, with what you pay set by your income.
Many health centers have on-site pharmacies that provide discounted prescription drugs, so the prescription itself is worth asking about there. When you ring the clinic to book, ask whether it has a pharmacy and whether it can fill the prescription you could not pay for. To find a clinic, search the Find a Health Center tool by city, state or ZIP code. Health centers are in all U.S. states, territories and the District of Columbia, so the tool covers the five areas where Extra Help is not available.
Ways people cope while they wait, and the ones you can decide on your own
Two of the ways people cope are yours to decide on your own, because neither changes how you take the medicine: asking whoever prescribed it for a cheaper one, and comparing prices. Ask the prescriber whether you can take a generic drug, or a cheaper brand-name drug if one is available, and compare pharmacies, since a mail-order pharmacy is sometimes cheaper.
Medicines sold by some websites are dangerous, even deadly, and an online pharmacy that offers deep discounts, or is not licensed by your state board of pharmacy, may be an unsafe one (see Is a cheap injection from a private seller safe to buy?).
Ways adults aged 18 to 64 save money on prescriptions include:
- skipping medication doses
- taking less medicine
- delaying filling a prescription
- asking a doctor for a lower-cost medication
- using alternative therapies
Skipping doses, taking less medicine and delaying a fill all mean not taking the medicine as prescribed, and cost-saving strategies like these may have implications for health and have been associated with more emergency room use and hospital stays compared with adults who take their medicine as recommended. Only the person who prescribed the medicine can say whether a dose can be skipped, made smaller or put off, so call the prescriber's office before your supply runs out and say that you cannot pay for this fill. Saying why gives them the chance to suggest a cheaper option. Tell the prescriber too if you are thinking of using an alternative therapy in place of the medicine.
If the prescription came from a physician NicoCares connected you with, that physician decides whether a cheaper option, or a change to how you take the medicine, is right for you. Message your care team about it on Spruce, the secure messaging app where they answer you, and send it as soon as you know the money will be short, well before your supply runs out, because NicoCares gives no time frame for an answer.
