Even with Medicare Part D coverage, prescription drugs can still come with shockingly high price tags.
Before we get into the article, it is worth mentioning that if you can find a drug plan with a formulary that covers your clients' prescriptions, the out-of-pocket-maximum for 2026 is $2,100 and expected to be approximately $2,400 in 2027. A considerable savings to paying the sticker price on some of these drugs.
However, if you cannot find a plan that covers client prescriptions, we suspect these five steps will be helpful to you and your clients!
While many common generics cost just a few dollars, some specialty medications can exceed $30,000 to $80,000 per month. For example:
- Mavenclad (MS treatment): ~$60,000 per treatment cycle
- Vitrakvi (targeted cancer therapy): ~$32,000 per month
- Duloxetine (generic Cymbalta)
- Timolol
- Restasis
- Xiidra
- Diclofenac
Fortunately, most clients aren’t dealing with drugs at that level, but many are still paying more than they should.
Common medications like the following can still cost hundreds of dollars depending on the plan, pharmacy, or timing in the coverage phases.
The good news? You can help clients significantly reduce their costs using these five strategies.
Step 1: Ask About a Generic
This is the easiest and most impactful savings opportunity.
Generic drugs:
- Use the same active ingredients as brand-name drugs
- Must meet strict FDA standards for safety, strength, and effectiveness
- Typically cost 80%–90% less
For example, switching from a brand-name drug to a generic can take a prescription from hundreds of dollars down to a fraction of the cost.
When generics aren’t available:
- Drug patents typically last around 20 years
- After expiration, generics still require FDA approval before hitting the market
If no generic exists (or your client is already using one) move on to the next option.
Step 2: Ask About Therapeutic Substitutes
If a generic isn’t helping enough, the next step is to ask about alternative medications that treat the same condition.
This is especially important when:
- A client is prescribed something mid-year
- The new drug isn’t on their plan’s formulary
In many cases, a substitute or sometimes even a brand-name drug may be covered better than the original prescription.
Example:
- Lansoprazole (generic Prevacid): ~$130
- Omeprazole (generic Prilosec): ~$60
Both treat GERD, but the cost difference is significant.
Step 3: Request Drug Samples (Short-Term Relief)
If switching medications isn’t an option, clients can ask their doctor for free samples.
Important notes:
- Usually limited to brand-name medications
- Designed to help patients get started.
While not a permanent fix, samples can save money immediately and/or buy time until a better solution is found (like plan changes during AEP).
Step 4: Compare Prices Outside of Medicare (GoodRx & More)
Sometimes, the best price isn’t through insurance at all.
Tools, like the following list, can provide dramatically lower costs.
- GoodRx
- Pharmacy price comparison tools
- Mail-order services
Keep in mind, if a client uses a coupon or discount program, the purchase won’t count toward their Part D deductible or out-of-pocket costs
But if the savings are large enough, that tradeoff often makes sense and can a major win for clients paying cash.
Real example:
- Duloxetine (3-month supply): ~$300+ retail
- Discounted via GoodRx: ~$25
A quick caution: Be careful with certain medications (like insulin) when ordering from unfamiliar or international pharmacies due to storage and shipping requirements.
Step 5: Explore a Special Enrollment Period (SEP) or Formulary Exception
If none of the above options solve the issue, the next step is usually to request a formulary exception from the current drug plan. This allows the client to try to get coverage for a medication that isn’t on the plan’s formulary. If approved, the plan can cover the drug for the remainder of the year, often making this the fastest way to address an immediate need (decisions are typically made within a few days).
However, approval isn’t guaranteed and depends on the provider demonstrating that all formulary alternatives are ineffective or inappropriate. Even when approved, the medication may still fall on a higher-cost tier.
If a formulary exception is denied, or if costs remain too high, consider applying for an SEP to switch drug plans. This makes sense when a medication isn’t covered or another plan offers significantly better pricing.
Example:
- Eliquis retail: ~$500+
- Covered under the right plan: ~$40
SEP approval isn’t guaranteed, and even when approved, the change typically doesn’t take effect until the following month. Because of that, it’s generally best used as a contingent strategy, rather than the first move.
Conclusion
Helping a client reduce their prescription costs, even by a few hundred dollars, can make a meaningful difference.
You’ve likely already helped them choose a Medicare plan. This is your opportunity to deliver even more value and build long-term trust.
Use these five steps consistently, and you’ll position yourself as a go-to resource, not just during AEP, but year-round.
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