How GoodRx Can Help Medicare Enrollees Reduce Their Medication Costs

Drugs can be one of the biggest costs you’ll face as a Medicare enrollee. And even if you aren’t currently taking medications, it’s likely you will need to at some point. So can GoodRx come in handy when you head to the pharmacy counter? Here’s a look at when you may want to consider using GoodRx if you have Medicare.

What medication costs are currently covered under Medicare? Under Medicare, your medications are covered under Medicare Part D, which is medication coverage that’s added to other Medicare plans. Medicare prescription drug coverage will cover prescription medications. However, it won’t cover drugs that you receive during an inpatient hospital stay or in an outpatient hospital setting. Part D also won’t cover over-the-counter medications. But it will cover certain medications that you inject, such as insulin.Each Part D drug plan has its own list of covered drugs, also known as the plan’s “formulary.” Before you decide whether to use GoodRx or Medicare, check to see if your medication is on the formulary. If the formulary doesn’t include your medication, ask your healthcare provider if there’s a similar medication on the formulary or if they can help you get an exception for coverage. Can you use GoodRx to lower Medicare out-of-pocket costs for medications? You can’t use Medicare and GoodRx at the same time. But you can use GoodRx instead of Medicare (in the next section, we’ll explain when it might make sense to do this).

If you use GoodRx instead of Medicare, you need to ask the pharmacist not to run your prescription through your Medicare. Show them your GoodRx coupon, and ask them to run the transaction as cash instead.

This means you'll be paying the "cash" price. But take note: When you pay the cash price rather than purchasing your medication through your Medicare Part D plan, those costs will not be automatically counted toward your deductible or your true out of pocket (TrOOP) costs. TrOOP costs are the prescription drug costs that count toward the annual out-of-pocket threshold that you must reach before catastrophic drug coverage begins.

However, if you provide receipts for the transaction and submit an appeal to your Part D plan, your plan should credit what you paid out of pocket (up to the plan's copay price for the same drug) toward your deductible and out-of-pocket costs.

When should you use GoodRx instead of Medicare?

There are some situations where you may want to consider using GoodRx instead of Medicare, such as when:

• Your medication isn’t covered by Medicare. If this is the case, GoodRx may be able to help you save on the cash price. GoodRx can also help you save on over-the-counter medications and vaccines.

• GoodRx prices are lower than your Medicare copay. In some cases — but not all — GoodRx may offer a cheaper price than what you’d pay under Medicare. 

• You won’t reach your annual deductible. If you know you won’t meet your Medicare plan’s deductible for the year, it might make sense to use GoodRx. If you won’t benefit from your plan’s “initial coverage” because you won’t ever pay enough toward your deductible to qualify for it, then you may not want to put any more money toward the deductible.

• You’re in the donut hole. The “coverage gap” or “donut hole” phase of your Medicare plan typically means you don’t get as much coverage for your medications. GoodRx cash prices can be cheaper than Medicare copays during this period. 

• You want to stay out of the donut hole. If you’re nearing the donut hole phase and you won’t be able to afford your medications with less coverage, you might decide to use GoodRx instead of continuing to pay for your medications using Medicare. 

Are GoodRx cash prices always cheaper than Medicare copays?

Not always, but GoodRx can offer the most affordable price on many prescriptions. So check GoodRx before going to the pharmacy, especially if you have just been prescribed a new medication or your plan has changed its pricing.

Can you use GoodRx coupons to avoid Medicare coverage gaps or get out of them?

You can’t use GoodRx coupons to get out of the Medicare donut hole once you’re in it. But you can “avoid” it by using GoodRx instead of paying donut-hole prices.

And, as mentioned above, if you’re about to hit the donut hole and know you won’t be able to afford the medication costs once you’re in it, you may want to use GoodRx discounts instead of continuing to use Medicare with less coverage. 

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Why is less prescription drug coverage available during Medicare coverage gaps?

In the coverage gap, or donut-hole stage, you’re responsible for paying a percentage of the full cost of your drug (e.g., coinsurance). In 2022, you’ll be responsible for paying 25% of the cost of brand-name drugs and generic drugs. 

The coverage gap was originally included to reduce the total 10-year cost of the Part D program. Congress has begun to phase out the coverage gap by reducing the costs paid in the gap by Part D enrollees and plans. They’ve also required drug manufacturers to offer discounted prices on brand-name drugs to enrollees. But enrollees in this phase are still responsible for a large chunk of their medication costs.

To get out of the donut hole in 2022, you have to spend a total of $7,050 on your drugs. However, you do get credit for all the money you spent while in the earlier two phases. 

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Written by:

Dan Wagener, MA

Dan Wagener, MA, is an editor and writer with experience in healthcare, mental health, and prescription drug use and misuse. At GoodRx, he worked on stories about drug prices, co-pay cards, prescription trends, telehealth, and more.

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