Illuminate
Pharmacy Benefits: Key to Health, Safety, and Adherence
September 22, 2025
When people are considering a new prescription drug plan, they are often interested in what medications are covered under the plan’s formulary, or drug list. Over half of all adults in the U.S. take one or more prescription medications for chronic illnesses such as asthma, diabetes, and hypertension; and older adults commonly take multiple medications. Pharmacy benefits help enable people to live longer, manage their illnesses better, stay out of the hospital and emergency room, and enjoy a better quality of life. By working with residents to make sure they get the medications they need and can take them as directed, senior living communities help seniors to age in place and live with joy and purpose.
Traditionally, pharmacy benefits include prescription drug coverage, co-payments, and formulary management. Coverage depends on the beneficiary’s insurance plan and its formulary. Plans usually cover some medications for common conditions; however, they may only cover specific generic or brand name products.
Formularies can change from year to year, so residents need to stay up to date on their plan’s coverage options, particularly if they get a new diagnosis that requires a medication be added to their regimen. Residents also need to know what kinds of co-payments are required for their prescriptions. While pharmacy benefits are usually part of overall insurance coverage, they differ from medical 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 can self-administer. It is important for senior living residents to have access to the care and support they need when it comes to all types of medications.
The Cost Conundrum
Many seniors count on pharmacy benefits to manage their medication costs. Without these benefits, expenses for drugs could be prohibitive, placing a serious financial burden on individuals who are often already living on fixed incomes. 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. These actions can lead to complications that result in emergency room visits and hospitalizations.
In fact, cost is one of the main reasons people don’t adhere to their medication regimens. In a recent survey of adults aged 65 and older, more than 20% of respondents reported non-adherence due to cost issues in the past year. At the same time, nearly 90% said they would be interested in their physicians using real-time prescription benefit tools to help them manage drug costs. Another study noted that people 65 and older reported not filling prescriptions or taking medications as prescribed because of cost. The authors notes that “cost-related non-adherence was six times higher among older adults who were food insecure compared with those who food secure.”
While the reasons for cost-related non-adherence may vary, there is no question about the negative consequences. One literature review concluded that medication non-adherence may be associated with all-cause hospitalization and mortality in older adults. Not taking medications as prescribed may also lead to avoidable complications, such as anxiety, headaches, sleep problems, fatigue, mood or cognitive changes, nausea, and pain or other physical discomfort.
Pharmacy Benefit Tips and Tools
Pharmacy benefits provide access to cost-effective care in several ways:
• Access to 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. This involves medications that are categorized in 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. It is important to look at copays or out-of-pocket expenses related to higher-tier medications. Even when there isn’t a generic available, residents can talk to their physician or pharmacist to determine if there is a lower-cost alternative, such as a similar product that only requires one pill per day instead of two or three.
• Discount programs. These aren’t insurance, but cards, apps, or coupons designed to enable people to access medications at a lower cost. Many have no application or membership fee and are available to individuals without insurance.
• Extra Help. Medicare Part D has an “Extra Help” subsidy that helps pay for medications for individuals with limited income and resources. Those who are eligible get benefits such as no drug plan premiums, no deductibles, and a limit on the out-of-pocket cost for covered drugs.
• State assistance programs. State Pharmaceutical Assistance Programs (SPAPs) are available in some states to help eligible individuals pay for prescriptions. Some programs provide “wraparound coverage” for Medicare Part D plans, which helps cover costs of prescriptions drugs that the plans don’t pay for. Others offer targeted programs for specific populations such as older adults, disabled individuals, and people with HIV/AIDS. Many states also have discount programs, sometimes called “prescription buying clubs” or “discount cards,” that provide lower-cost medications by purchasing them in large quantities and passing the 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. A few of these are listed here.
Open Enrollment Options
Pharmacy benefit managers may change their drug formularies and pricing from year to year, so senior living residents need to stay on top of what their plans cover. 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 someone is satisfied with their current drug plan, it is worth comparing plans to see if a more affordable option exists.
According to Medicare.gov, 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, anticonvulsants, and antipsychotics.
If a medication someone needs is not on their plan’s formulary, they can use the Open Enrollment period to seek a plan that does include it. In the meantime, they can work with their prescriber to request an exception. This requires supporting documentation explaining the medical need for that medication.
The Medicare Plan Finder can help beneficiaries 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 and can help ensure they have access to the medications they need. Pharmacists can also work with residents to find opportunities to reduce the number of medications they take by identifying duplicate medications or drugs that are no longer necessary. These efforts can not only save costs but may also improve health and well-being. 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 co-pays, 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 consistent 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 were having side effects that they didn’t realize were caused by the 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 can benefit from a pharmacy partner who can help them successfully manage their conditions while minimizing risk and maximizing their quality of life. Consultant pharmacists offer a variety of services including person centered medication regimen reviews, tailored training for staff, clinical programs to address emerging issues and regulations, and guidance on state and federal compliance concerns.
Grueb added, “Navigating insurances and formularies can be hard for anyone, so having a pharmacist who can assist with alternatives to high-cost medications can be essential to help residents and communities manage costs. We also often see the ‘prescribing cascade’ where side effects occur from medications, so more medications are prescribed to control the side effects. Pharmacists are trained to spot these occurrences and offer solutions.”