How Pharmacy Benefits Help Lower Costs, Improve Health and Quality of Life
October 8, 2025
When you or your loved one is considering a new prescription drug plan, it is important to look at what medications are covered. Over half of all adults in the U.S. take one or more prescription medication for chronic illnesses such as asthma, diabetes, and hypertension. Older adults commonly take multiple medications. Pharmacy benefits, along with the support and guidance of the pharmacist, can help seniors manage their chronic conditions, stay safe and active, and avoid emergency room visits and hospital stays.
Traditionally, pharmacy benefits include prescription drug coverage, but they also may involve counseling, education, and medication management and support. Coverage depends on the insurance plan and its formulary, which is the list of covered drugs. Plans usually cover some medications for common conditions; however, they may only cover specific generic or brand name products. It is also important to know what kinds of copays, or out-of-pocket costs, are involved. The amount of copay required varies with each plan and with each medication.
While pharmacy benefits are usually part of overall insurance coverage, it is important to note the difference between medical and pharmacy benefits. Medical benefits cover treatments and medications administered by a health care provider, such as a physician or a nurse. Pharmacy benefits involve medications that residents administer to themselves.
How Pharmacy Benefits Help Save Costs
Many seniors count on pharmacy benefits to manage their medication costs. Without these benefits, medication expenses can pose a serious financial burden. When people can’t afford their prescription medications, they may take steps such as skipping doses, cutting pills in half, or not getting prescriptions filled at all. These actions can lead to problems – such as headaches, sleep difficulties, nausea, and pain – that result in emergency room visits and hospitalizations.
If drug costs are unaffordable or putting a strain on your or your loved one’s budget, talk to your physician or pharmacist. They may be able to identify less costly medication alternatives. At the same time, there are several ways that pharmacy benefits provide access to cost-effective medication management:
- In-network pharmacies. These pharmacies provide access to medications on the plan’s formulary and often provide other services, such as delivery, medication reviews, and consultations.
- Tiered pricing. Medication pricing may be divided into tiers, usually with generic products in the lower-cost tiers and brand-names in the higher-cost ones. Beneficiaries can select generic medications, when available, to save money. Even when there isn’t a generic available, you can talk to a physician or pharmacist to determine if there is a lower-cost alternative.
- Discount programs. These are cards, apps, or coupons designed to provide access to lower
drug costs. Many have no application or membership fee and are available to individuals without
insurance. - Extra Help. Medicare Part D has an “Extra Help” subsidy to help pay for medications for people with limited income and resources. Those who are eligible get benefits such as no drug plan premiums, no deductibles, and a limit on their out-of-pocket cost for covered drugs.
- State assistance programs. State Pharmaceutical Assistance Programs (SPAPs) are available in some states to help eligible people pay for prescriptions. Some programs provide “wraparound coverage” for Medicare Part D plans by helping to cover prescription costs that the plans don’t. Many states also have discount programs, such as prescription buying clubs or discount cards, that serve the same purpose – providing lower-cost medications by purchasing them in large quantities and passing savings on to consumers.
- Pharmaceutical manufacturers’ Patient Assistance Programs (PAPs). Some pharmaceutical companies have special programs to help people pay for medications or even provide them for free. Eligibility is generally limited to people who are uninsured or those who don’t qualify for other programs such as Extra Help.
- National charity programs. There are numerous national programs that provide financial assistance for prescription medications and/or guidance on local or regional programs that can help.
Open Enrollment Options
Health plans may change their drug formularies and pricing from year to year, so it’s important to stay on top of what your plan covers. The good news is that the annual Medicare Open Enrollment period, from October 15 to December 7, enables Medicare beneficiaries to switch their prescription drug plans for the following year. Even if you are satisfied with your current plan, it is worth comparing plans to see if there is a more affordable option. It is especially important to review the formulary if you have experienced a new diagnosis and/or added a new medication in the past year.
According to the Medicare.gov website, all Medicare drug (Part D) plans must cover a “wide range of prescription drugs that people with Medicare take, including most drugs in certain protected classes.” These include drugs to treat cancer, HIV/AIDS, and depression, plus medications such as immunosuppressants for organ transplants, seizure medications, and antipsychotics.
It is worth noting that people can access drugs that aren’t on their plan’s formulary, but they will have to pay more for them. If a medication isn’t on your plan’s formulary, you can use the Open Enrollment period to seek a plan that does cover that drug. In the meantime, you can work with your prescriber to request an exception.
The Medicare Plan Finder can help you in these efforts. State Health Insurance Assistance Programs (SHIP) also can offer some support and guidance.
Pharmacists as Partners
The pharmacist is an important partner for senior living residents. They can help ensure access to needed medications and can also help find opportunities to reduce the number of medications taken by identifying duplicates or medications that are no longer necessary. These efforts can save costs and improve health. As Chad Worz, PharmD, BCGP, FASCP, CEO of the American Society of Consultant Pharmacists (ASCP), observed, “No one wants adverse effects or to pay for medications that don’t work or gum up the works.” He added, “Navigating insurance and working with physicians to find the medications that work best for people is a pharmacist’s superpower. This means fewer medications, lower copays, and much better quality of life.”
Consultant pharmacists can be very useful in a senior living setting, where residents are more independent and may not have regular contact with a health care provider. “I have seen real-life impact from a consultant pharmacist sitting with a resident to discuss their medications and learning that they are having side effects that they didn’t realize were from their medications. The pharmacist was able to educate them so they could reach out to their doctor to discuss alternatives,” said Katherine Grueb, PharmD, BCGP, PharMerica’s lead consultant pharmacist for New England. Grueb and the team at PharMerica know that senior living residents need a pharmacy partner who can help them successfully manage their conditions and maximize their quality of life.
Want to Know More?