State Pharmaceutical Assistance Programs (SPAP) and Medication Costs

Nearly one in four older adults say it’s difficult to afford their prescription drugs. Who struggles the most? Those in fair or poor health as well as those with low incomes. With this difficulty comes a tendency to skip prescription medication doses, cut pills in half, not fill prescription drugs, or take an over-the-counter medication instead.

The good news is that state pharmaceutical assistance programs may help offset some of these costs. This article explains how those programs work with Medicare Part D and how you can find more information about programs in your state.

Why Are Prescription Drugs So Expensive?

It’s simple: Pharmaceutical companies set their own prescription drug prices. When demand for prescription medications is high (think: medications for treating common conditions like high cholesterol, high blood pressure, and diabetes), pharmaceutical companies often raise the price.

In addition, when a drug manufacturer holds the patent rights to a new prescription medication, it has a monopoly on the drug for the 20-year duration of the patent. During that time, it can raise the price as frequently and as much as the market will bear.

How Does Cost Affect Someone’s Ability to Take Their Prescription Medications As Prescribed?

There’s no doubt about it: Cost can be a major barrier. In fact, 21% of older adults don’t take their prescription medicines as prescribed simply because of the cost. This is particularly true for Medicare beneficiaries who reach the Medicare Part D catastrophic threshold. In 2024, this amount is $7,400.

Unless these beneficiaries qualify for Medicare Part D low-income subsidies, they’re required to pay five percent of their total prescription drug costs once the $7,400 out-of-pocket threshold has been met. Those taking high-cost specialty drugs for cancer, multiple sclerosis, rheumatoid arthritis, or hepatitis C may pay thousands of dollars in out-of-pocket costs for their medications once they exceed this threshold.

What Are State Pharmaceutical Assistance Programs?

State pharmaceutical assistance programs are designed to help residents pay for prescription drugs. Note that pharmaceutical companies themselves may also offer programs to help people with Medicare Part D pay for prescription drugs. These are separate from state programs.

Who Is Eligible to Participate In Patient Assistance Programs?

Each program works differently in terms of who is eligible, so it’s important to do your homework before signing up.

For example, in some states, only those with HIV/AIDS or who have end-stage-renal disease are eligible while other states’ programs have broader criteria and are open to all people over the age of 65 or those with Medicare. The criteria between these programs can vary widely.

How Do Patient Assistance Programs Work With Medicare Part D?

It will vary by state. Your best option is to check with your state’s program. If your state requires you to sign up for Medicare Part D to receive assistance, it might be in your best interest to do so. Why? If a prescription drug is covered by both your drug assistance program and your Part D plan, the amount you pay – plus the amount covered by the assistance program – may count toward your out-of-pocket maximum.

In addition, your state’s pharmaceutical assistance program may help you pay for your Medicare Part D plan’s premium, deductible, and copayments. Also, certain states have qualified drug assistance programs, which means they provide a special enrollment period for you to enroll in or make changes to your Part D or Medicare Advantage coverage.

How Can I Learn More About Prescription Drug Assistance Programs in My State?

First, determine whether your state has a drug assistance program. If it does, reach out to the program directly and ask these questions. You can also talk to your doctor or pharmacist for more information about financial assistance programs or whether there is a lower-cost alternative for your medication.