Estimating Prescription Drug Costs
By Daniel Petkevich
May 25, 2020
How our software figures out what you'll pay for prescriptions this year.
Predicting your medical expenses in a given year is difficult. You know you'll likely make one routine visit to the doctor and seek treatment for recurring conditions, but whether you'll go to urgent care to treat a spider bite or, end up in the emergency room because of a broken leg, is up to chance.
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But one of your healthcare expenses is relatively easy to estimate: what you'll pay for prescription drugs in a given year. To recommend what prescription drug plan is best for you, we estimate how much each one will cost you over the course of the year and then suggest the lowest cost one. In this post, I'll explain how we do it. But first, a primer on Prescription Drug Plans.
Prescription Drug Plan (PDP) Components
The elements of a PDP that determine its costs are:
Monthly Premium
What you pay every month to be insured.
Drug Tiers
Each PDP has a formulary, or list of drugs that it covers. Each drug is grouped into one of five tiers below.
Tier 1: Preferred Generic
Tier 2: Generic
Tier 3: Preferred Brand
Tier 4: Non-Preferred Drug
Tier 5: Specialty.
Your coverage decreases as tiers increase. For example, your plan might have a copay of $1 for tier one drugs, but only cover 25% of the cost for tier 5 drugs.
Deductible
Many PDP plans are marketed as having a single deductible, but if you read the fine print, you'll see that some plans cover tier 1 and tier 2 drugs before the deductible is met. Plans cannot have a deductible higher than $590 per calendar year in 2025.
Coverage Phases
Deductible: Between 0 and $590
Initial Coverage: You pay copays and coinsurance as outlined in the plan, up to $2,000.
Catastrophic Phase: You're done. The plan pays the rest of our drug costs.
Putting It All Together
We combine all of the above concepts to create a personalized month-by-month estimate of what you'll pay for your prescriptions drugs.
Each month we add up:
Your premium
What you'll spend on each prescription. We do this by cross-referencing your prescriptions with the plan's formulary. We estimate the retail price of the drug using data from GoodRx. Depending on your TrOOP, the amount of coverage your plan will provide for a given drug will vary.
We then suggest the plan with the lowest estimated total expenditure (premium and drug costs).
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Virgil Insurance Agency, LLC (DBA Fair Square Medicare) and www.fairsquaremedicare.com are privately owned and operated by Help Button Inc. Medicare supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. This is a solicitation of insurance. A licensed agent/producer may contact you. Medicare Supplement insurance is available to those age 65 and older enrolled in Medicare Parts A and B and, in some states, to those under age 65 eligible for Medicare due to disability or End-Stage Renal disease. Virgil Insurance Agency is a licensed and certified representative of Medicare Advantage HMO, HMO SNP, PPO, PPO SNP and PFFS organizations and stand-alone PDP prescription drug plans. Each of the organizations we represent has a Medicare contract. Enrollment in any plan depends on contract renewal. The plans we represent do not discriminate on the basis of race, color, national origin, age, disability, or sex. Plan availability varies by region and state. For a complete list of available plans please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov. © 2025 Help Button Inc
We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.
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