Drug costs: counselor explains out-of-pocket caps, formularies and why plan choice matters

During the program, LaPrade reviewed how prescription coverage has changed in recent years and why it matters for beneficiaries with high drug needs.

"What they've done is they've eliminated that donut hole. Now there's a... I think it was 2 years ago, they set a maximum of $2,000 ... Last year, I think it went up to 2,100... 2,200 this past year," he said, adding that he expects the figure could rise again. He stressed that only prescriptions covered by a given drug plan count toward that annual out-of-pocket maximum.

LaPrade advised viewers to check the Plan Finder for quantity limits, step-therapy requirements and any restrictions listed at the bottom of a plan’s formulary. He recommended bringing a complete list of current medications to a SHINE appointment so the counselor can confirm which plans cover those drugs and where they will count toward the out-of-pocket threshold.