By Patricia Prewitt
My Personal Rx Adviser
With the arrival of 2025, you may be noticing changes to copays or coverage for your medications. I hope these changes are working in your favor. Here are a few reasons why changes occur:
Formulary negotiations: Brand-name manufacturers of medications negotiate their placement on insurance formularies annually, which can result in tier and price changes for the consumer.
Higher-tier generics: Pharmacy benefit managers (PBMs) like CVSCaremark/ExpressScripts often review high-cost generic medications and may move them to higher tiers, or eliminate coverage, increasing costs for the patient.
Why prices vary
Think about how prices are different for the same household item at Target, Walmart, and other stores. One store might have a sale, or the customer might have a manufacturer’s coupon to reduce the cost. For medications, it’s not uncommon for two people taking the same medication to pay different prices, depending on the insurance plan. This can be true for all types of prescription plans, including government-sponsored and traditional types of commercial insurance.
Prescription pricing is not transparent, since there are so many entities involved. Factors include the plan’s formulary tier, PBM rebates, pharmacy pricing, supply chain costs, average wholesale price, acquisition costs, and more. These factors, along with processing rules specific to commercial prescription insurance plans, Medicare Advantage Plans, and Medicare Part D plans, result in lots of pricing confusion for both health care providers and patients.
When to use a savings card
A friend recently discovered that a monthly medication would cost $38.51 using her Rx plan benefit. Checking GoodRx, she found a price of $17.44 – a $20+ savings! But the savings didn’t stop there. I suggested she check SingleCare, and she found an even lower price of $9.31.
Now, the choice was up to her how she wanted to pay for her prescription. SingleCare showed a price of $7.40 at a different pharmacy, but it required transferring the prescription. Consumer education is key. There are now many options to save money that bypass Rx insurance.
Practical tips for using savings cards
Compare prices: Always compare savings card prices to the cost of filling the needed Rx using your prescription plan. Prices change frequently and vary by medication, zip code, and store.
In general, I have found savings cards work best for generically available products used to treat chronic diseases that are priced at $15 or more for a 30-day supply.
Do prescriptions filled using a savings card count toward my prescription insurance plan deductible?
No. These costs will not usually be accrued towards a deductible. You are not using your insurance! Using a savings card turns your purchase into a direct-to-consumer transaction.
Feedback from my Inbox:
Reader LW writes: “I think you should have made it clear that the $2,000 out-of-pocket cap for Medicare enrollees only applies to prescription drugs and not all Medicare expenses. When I first read it, (January edition, ‘What’s new for Medicare in 2025?’) I thought it was a cap on all out-of-pocket expenses.”
From the Author: LW, I agree. I try diligently to provide clarity for readers, not to cause more confusion! Thank you for bringing this to my attention. The new 2025 $2,000 out-of-pocket cap only applies to the prescription portion of Medicare known as Part D. Medicare Advantage Plans known as Part C Plans, often include drug coverage. It remains to be seen how these new rules will be implemented.
Content provided is for educational purposes only, and is not intended as a substitute for advice from a qualified medical professional. The opinions expressed within are th
