Medicare Prescription Drug Costs Out of Control? Understanding Part D and MOOP
💊 Prescription costs are one of the biggest frustrations seniors face when they first enroll in Medicare. Part D is supposed to help, but formularies, copays, and coverage gaps often leave retirees paying more than expected. And while Medicare Advantage plans may include drug coverage, the out-of-pocket costs can climb until you hit your Maximum Out-of-Pocket (MOOP) limit.
That’s where Palmetto Mutual comes in. Our local experts make sense of confusing rules and explain — in plain English — how Part D works, what MOOP really means, and the steps you can take to keep your prescription costs under control in 2025. Whether you live in Myrtle Beach (ZIP 29577), Florence (29501), or smaller towns like Nichols (29581), this guide is designed to help you protect both your health and your wallet.
Why Prescription Drug Costs Keep Rising for Seniors
Like sand slipping through an hourglass ⏳, prescription prices seem to flow in only one direction — up. Every year, seniors across Horry, Florence, and Georgetown counties watch helplessly as their medication bills climb, even when they’ve done everything right with their Medicare coverage.
💬 Diana’s Story
⚠️ This is a fictional story based on real Medicare situations seniors face.
Diana, enjoying retirement by the beach in Myrtle Beach (ZIP 29577), thought her prescription costs were locked in. Then her heart medication jumped from $35 to more than $300 without warning. After reviewing her options, she switched to a Part D plan that worked with her local pharmacy.
👉 “Now I don’t have to wonder what the price will be each month,” Diana said.
💊 The Real Forces Behind Rising Drug Prices
Several players affect the final price at the pharmacy counter:
- Drug manufacturers set high launch prices for new medications.
- Insurance companies adjust coverage rules each year.
- Pharmacy Benefit Managers (PBMs) negotiate discounts but may not pass savings along.
A brand-name pill prescribed in Florence (ZIP 29505) can easily cost ten times more than the same medication in generic form — draining your budget faster than you expect.
🔄 How Formulary Changes Catch Seniors Off Guard
Your plan’s formulary is the list of drugs it covers. Each January, this list can change.
- A drug that cost $10 in 2024 might suddenly move to a higher tier in 2025.
- Some drugs may now require prior authorization from your doctor.
- Copays can triple overnight if your medication is reclassified.
For example, a senior in Georgetown (ZIP 29440) discovered her thyroid medication was no longer “preferred,” raising her monthly cost from $8 to $42.
📈 Why Generic Alternatives Don’t Always Save Money
Generics are usually cheaper, but not always:
Mail-order options in places like Conway (ZIP 29526) can sometimes help — but only if your plan allows it.
Some specialty generics still cost hundreds of dollars a month.
If your doctor writes “dispense as written,” you may be forced to buy the expensive brand even when a generic is available.
Why Prescription Drug Costs Keep Rising for Seniors
⏳ Like sand slipping through an hourglass, prescription prices seem to flow in only one direction — up. Each year, seniors across South Carolina and North Carolina watch as medication costs rise, even when they’ve done everything right with their Medicare coverage.
Diana’s Story 💬
⚠️ The following story is a fictional example based on real-life Medicare situations commonly experienced by seniors across the United States.
Diana, a retiree enjoying the beach near Surfside (ZIP 29575), thought her prescription costs were steady. Then her heart medication jumped from $35 to more than $300 without warning. After reviewing her options, she switched to a Part D plan that worked with her local CVS in Myrtle Beach.
“Now I don’t have to wonder what the price will be each month,” Diana says.
Her experience shows how quickly costs can shift — and why staying proactive matters.
💊 The Real Forces Behind Rising Drug Prices
- Drug manufacturers set steep launch prices for new medications.
- Insurance companies adjust cost-sharing each year.
- Pharmacy Benefit Managers (PBMs) negotiate behind the scenes, often leaving seniors stuck with the bill.
When a new brand-name drug hits Florence pharmacies, it often comes with a shocking price tag that can drain your budget faster than expected.
🔄 How Formulary Changes Catch Seniors Off Guard
Your plan’s formulary — the official list of covered medications — changes every year. A blood pressure drug covered in 2024 may suddenly require prior authorization in 2025, or move to a higher tier. That could triple your copay at local pharmacies like Walgreens in Darlington (ZIP 29532).
📈 Why Generic Alternatives Don’t Always Save Money
While generics usually cost less, some “specialty generics” still carry hefty price tags. And if your doctor writes “dispense as written,” you’ll be forced to pay for the brand-name version — even when a generic exists.
For example, a retiree in Conway (ZIP 29526) discovered her cholesterol medication had a generic available, but her doctor’s prescription instructions locked her into the higher-cost brand until she requested a change.
How Medicare Part D Works in 2025
🚨 Think of Part D like a fire drill at school. You don’t wait until the alarm sounds to figure out where to go — you plan ahead. The same is true with your drug coverage.
Here’s what to know RIGHT NOW about Medicare Part D in 2025:
- 🚨 URGENT: If you don’t have Part D and you’re eligible, you’re adding lifetime late penalties every single month you delay.
- 🚨 CRITICAL: Your 2024 plan may not cover your 2025 prescriptions — check now before January.
- 🚨 IMMEDIATE: The donut hole (coverage gap) still exists in 2025, despite rumors that it was gone.
- 🚨 ACTION NEEDED: Pharmacy networks change every year. Walgreens might be “preferred” on one plan, while CVS is preferred on another.
✅ Understanding Your Part D Premium and Deductible
⚠️ The following testimonial is a fictional example based on real Medicare situations.
Christine, a retired chef from Myrtle Beach (ZIP 29577), almost signed up for a plan on the spot at a seminar. But a neighbor reminded her to compare options.
“Good thing I listened — I found one that covers my prescriptions for far less.”
In 2025, the standard Part D deductible is $545. Some plans advertise $0 deductibles, but those usually come with higher premiums or tighter restrictions on which drugs are covered.
🏥 How Your Plan’s Pharmacy Network Affects Costs
Using a preferred pharmacy in your plan’s network can save you 20–40%.
- In Florence (ZIP 29501), CVS may be the preferred option.
- In Georgetown (ZIP 29440), Walgreens might have the lower copays.
- In rural towns like Nichols (ZIP 29581), local independent pharmacies may not be included at all.
💰 The Four Stages of Drug Coverage Explained
To budget wisely, you need to know all four stages of Part D coverage:
- Deductible – you pay the full cost until the deductible is met.
- Initial Coverage – you pay copays or coinsurance.
- Coverage Gap (Donut Hole) – you pay 25% of drug costs until you reach catastrophic coverage.
- Catastrophic Coverage – once you hit $8,000 in out-of-pocket costs, you pay $0 for covered medications.
💊 Medicare Part D Drug Tiers Explained
| Drug Tier | What It Includes | Typical Copay | Preferred Pharmacy Copay |
|---|---|---|---|
| 🟢 Tier 1: Preferred Generic | Most common generics | $0–$5 | $0–$3 |
| 🔵 Tier 2: Generic | Other generics | $5–$20 | $3–$15 |
| 🟡 Tier 3: Preferred Brand | Lower-cost brand drugs | $35–$47 | $25–$40 |
| 🟠 Tier 4: Non-Preferred Brand | Higher-cost brands | 40–50% | 35–45% |
| 🔴 Tier 5: Specialty | Complex medications | 25–33% | 25–33% |
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👉 Part D formularies vary by plan — Palmetto Mutual can help you check if your prescriptions are really covered before you enroll.
The Stages of Part D Coverage: Deductible, Donut Hole, and Catastrophic
Think of your Part D coverage like a sieve 🪣. Some costs slip through easily, while others get caught at different levels. If you don’t understand these stages, you may be shocked at the pharmacy counter in Florence (ZIP 29501) or Conway (ZIP 29526).
📊 Stage 1: Meeting Your Annual Deductible
Before your plan pays anything, you cover the full drug costs up to your deductible.
- In 2025, that deductible can be as high as $545.
- For a senior in Darlington (ZIP 29532) taking three maintenance medications, this could mean paying $500+ in January alone.
🏪 Stage 2: Initial Coverage Period
After you’ve met your deductible, you enter the initial coverage stage. Here, you’ll pay set copays or coinsurance.
- This stage lasts until your combined drug costs (what you and the plan pay together) reach $5,030 in 2025.
- Example: A retiree in Georgetown (ZIP 29440) may pay $35 for a cholesterol drug and $10 for blood pressure medication until hitting that threshold.
🕳️ Stage 3: The Coverage Gap (Donut Hole)
This stage starts after you and your plan hit $5,030 in drug costs.
- You’ll pay 25% of the cost for both brand-name and generic drugs.
- This continues until your out-of-pocket spending reaches $8,000.
- For seniors taking specialty medications in Horry County (ZIP 29577), this stage can arrive quickly and feel like falling into a hole with no bottom.
💡 Cost Format #31 – Income-Based Plan Choice
In pricier areas, many seniors pick lower-premium Part D plans — around $22/month — thinking they’re saving money. This works well if you take only generics, but it can backfire badly if you later need brand-name or specialty drugs.
🛡️ Stage 4: Catastrophic Coverage
Once your out-of-pocket costs reach $8,000, you enter catastrophic coverage.
- In 2025, you’ll pay $0 for covered drugs in this stage.
- This is a major improvement from past years when seniors still had to pay 5% coinsurance.
For example, a retiree in Marion (ZIP 29571) who struggles with high-cost cancer medications could see their pharmacy bills drop from hundreds a month to nothing after reaching this stage.
What MOOP (Maximum Out-of-Pocket) Means for Medicare Beneficiaries
Many seniors hear about MOOP but misunderstand what it really covers. Let’s clear it up with a “What Grandma Got Wrong” format:
❌ What Grandma Thought: “Once I hit my MOOP, everything is free!”
✅ The Truth: MOOP only applies to Medicare Advantage plans, not Original Medicare, and your Part D drug costs usually don’t count toward it.
❌ What Grandma Thought: “My MOOP protects me from all medical costs.”
✅ The Truth: Out-of-network services and non-covered care (like dental or vision) usually don’t count.
❌ What Grandma Thought: “MOOP is the same for every plan.”
✅ The Truth: MOOP limits vary widely, from $3,500 to $8,850 in 2025, depending on your plan.
🎯 How MOOP Protects You From Runaway Medical Costs
⚠️ The following testimonial is a fictional example based on real-life Medicare situations.
Cheryl, a lifelong beachgoer in North Myrtle Beach (ZIP 29582), skipped Part D because a friend told her she didn’t need it. She ended up paying full price at the pharmacy all year.
“That was a painful mistake — one I’ll never repeat.”
MOOP is your safety net under Medicare Advantage. Once you hit the limit, your plan pays 100% of covered medical costs for the rest of the year.
💡 What Counts Toward Your MOOP (And What Doesn’t)
✅ Counts: Deductibles, copays, and coinsurance for in-network care.
❌ Doesn’t Count: Part D drug expenses, out-of-network care, and services your plan doesn’t cover.
This separation often surprises seniors. A retiree in Florence (ZIP 29505) hit her MOOP after hospital visits, yet still owed thousands in prescription copays because drug costs were tracked separately.
📊 2025 Medicare Plan Types at a Glance
| Plan Type | 2025 MOOP Range | Includes Part D? | Network Freedom | Best For |
|---|---|---|---|---|
| 🟢 HMO | $3,500–$7,500 | Sometimes | ❌ Limited | Cost-conscious seniors with local doctors |
| 🔵 PPO | $5,000–$8,850 | Sometimes | ⚖️ Moderate | Those who travel or want flexibility |
| ⚪ Original Medicare | 🚫 No MOOP limit | Separate Part D | ✅ Complete | Seniors wanting freedom to see any doctor |
| 🟣 Medigap + Part D | 🚫 No MOOP (percentage-based) | Separate Part D | ✅ Complete | Seniors seeking predictable costs |
How Part D and MOOP Work Together to Limit Costs
Trying to understand Part D and MOOP together can feel like walking through a mirror maze 🪞 — every turn shows another reflection of costs, and it’s hard to see the way out. But once you know how these two systems fit, the path becomes clearer.
Dolores’s Story 💬
⚠️ The following story is a fictional example based on real-life Medicare situations commonly experienced by seniors.
Dolores, the family chef in Dillon (ZIP 29536), always cooks Sunday dinner for her children and grandkids. She picked a low-premium Medicare Advantage plan, thinking she’d save money. But rising hospital copays and higher prescription costs began eating into her grocery budget.
After working with an advisor, she switched to a plan that lowered her copays while keeping her trusted local doctors.
“Now I can focus on cooking for my family instead of worrying about bills.”
Her story shows how medical costs (MOOP) and drug costs (Part D) can drain your budget separately unless carefully managed.
🔗 Why Your Drug Costs and Medical MOOP Are Separate
- Medical costs (doctor visits, hospital stays, outpatient care) count toward your MOOP.
- Drug costs under Part D are tracked separately.
- You might hit your medical MOOP after a surgery at McLeod Regional in Florence, but still face thousands in prescription costs at Walgreens or CVS.
📱 Strategies to Manage Both Types of Out-of-Pocket Costs
Smart seniors take these steps:
- Review both your drug plan and medical coverage together during the Annual Enrollment Period.
- Sometimes, picking a plan from the same insurer combines deductibles or lowers prescription costs.
- Check if your plan offers preferred pharmacy pricing in towns like Conway (ZIP 29526) or Sumter (ZIP 29150).
🏥 When Switching Plans Makes Financial Sense
If you’re consistently hitting high medical bills and paying a lot for prescriptions, a higher-premium plan with a lower MOOP may actually save you money.
For example:
- A $0 premium plan in Georgetown (ZIP 29440) might seem attractive.
- But if you’re paying thousands annually in drug copays, a $40/month premium plan with lower drug tiers could be far cheaper overall.
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👉 Hitting your MOOP can protect you from runaway medical costs — Palmetto Mutual’s experts will show you how Part D and MOOP limits really work for your situation.
Common Mistakes Seniors Make with Prescription Coverage
When it comes to Medicare drug coverage, many seniors fall into traps without realizing it. Let’s use The Big Reveal 🎭 format to make these mistakes crystal clear:
🎭 The Setup: “I’ve had the same Part D plan for five years — it must still be good!”
💥 The Reveal: Your plan’s formulary changed three times, your pharmacy left the network, and you’re overpaying by $1,800 annually.
🎭 The Setup: “I don’t take many medications, so I picked the cheapest plan.”
💥 The Reveal: When you needed antibiotics after surgery in Conway (ZIP 29526), they weren’t covered — and you paid $400 out-of-pocket.
🎭 The Setup: “My friend loves her plan, so I signed up for the same one.”
💥 The Reveal: Her prescriptions are totally different from yours. You’re paying triple what you need to at the CVS in Florence (ZIP 29501).
🚫 Assuming Your Plan Stays the Same Year to Year
Part D plans change every January. Formularies, pharmacy networks, and cost structures may shift, even if your premium looks the same. What worked in 2024 could be a budget disaster in 2025.
💊 Not Checking If New Prescriptions Are Covered
⚠️ The following testimonial is a fictional example based on real-life Medicare situations commonly experienced by seniors.
Christine, a longtime public radio supporter from Darlington (ZIP 29532), once thought drug plans were just a trick to get more money.
“Then I realized without one, I’d be paying thousands each year out-of-pocket. Having Part D and knowing my MOOP keeps my costs under control.”
Always verify new medications before filling them. A retired teacher in Florence discovered her arthritis drug wasn’t on her plan — the bill? $600 at checkout.
💡 Cost Format #32 – Snowbird ZIP Cost Note
Snowbirds splitting time between South Carolina and Florida often pay slightly higher Part D premiums (around $30/month). That’s because networks adjust for retirees moving between ZIPs. Always update your address to see the correct plans.
🔍 Ignoring Medicare Plan Finder Tools
Medicare.gov’s Plan Finder is free and powerful. Enter your medications, dosages, and pharmacies to see true annual costs. Seniors who skip it often spend hundreds more each year without realizing it.
Extra Help Programs That Reduce Part D Costs
Managing prescriptions can feel overwhelming, but there are programs designed to bring relief. Think of them like a thermometer 🌡️ — the higher your financial need, the more support you receive. Even if you’re “comfortable,” you may still qualify for help.
💰 Understanding the Extra Help / Low Income Subsidy
The Extra Help program lowers premiums, deductibles, and copays for seniors who qualify.
- In 2025, individuals with incomes below $22,590 (or couples below $30,660) may qualify.
- Even if you have savings, you may still be eligible.
Example: A retiree in Sumter (ZIP 29150) qualified for Extra Help and saw her monthly medication costs drop from $280 to under $50.
🏥 State Pharmaceutical Assistance Programs (SPAPs)
Twenty-three states have SPAPs that work alongside Part D.
- In Pennsylvania, programs like PACE/PACENET can save seniors $2,000 a year.
- South Carolina doesn’t currently run a state-wide SPAP, but many local churches and community centers in Florence and Horry counties connect seniors with charity-based medication programs.
💊 Manufacturer Assistance and Discount Programs
Drug companies often offer savings cards or direct help for costly brand-name drugs.
- Copays can drop to as little as $10–$35 per month.
- A Myrtle Beach (ZIP 29577) retiree used a manufacturer card for her diabetes medication, cutting her bill from $400 down to $30.
⚠️ Costly Medicare Part D Mistakes & How to Avoid Them
| What They Did | What Happened | What They Should Have Done |
|---|---|---|
| 💰 “I didn’t apply for Extra Help because I have savings.” | Paid $300/month for meds unnecessarily | ✅ Remember: Savings under $30,000 don’t disqualify you |
| 📬 “I ignored the state assistance program mailer.” | Missed $150/month in benefits | ✅ SPAPs often stack with Part D — double the savings |
| 💊 “I didn’t mention my prescriptions when enrolling.” | Picked a plan that didn’t cover a main medication | ✅ Always list all current prescriptions when enrolling |
| 🧾 “I assumed Medicare covered everything.” | Faced $500 monthly drug bills | ✅ Part D is separate and essential for drug coverage |
| ⏰ “I waited to enroll in Part D until I needed it.” | Stuck with lifetime late penalties | ✅ Enroll as soon as eligible to avoid extra costs |
How to Compare Part D Plans for Your Medications
Choosing a Part D plan isn’t just about picking the cheapest premium — it’s about matching your exact medications and pharmacy needs. To make it simple, let’s play a quick “Would You Rather 🤔” game.
Would You Rather…
🤔 Pay $10/month premium with $45 generic copays?
OR
Pay $35/month premium with $5 generic copays?
👉 If you take 3+ generics monthly, the higher premium plan saves you money.
🤔 Use any pharmacy with standard copays?
OR
Use only CVS/Walgreens for 40% lower copays?
👉 Preferred networks save money — but only if they’re convenient in your ZIP.
🤔 Have a $545 deductible with lower premiums?
OR
Have $0 deductible with $20 higher monthly premium?
👉 High medication users should pick the $0 deductible plan.
🔍 Using Medicare Plan Finder Effectively
⚠️ The following testimonial is a fictional example based on real-life Medicare situations commonly experienced by seniors.
A senior in Florence (ZIP 29505) entered her exact prescriptions into the Medicare Plan Finder and discovered she could save $1,200 a year just by switching plans.
“I wish someone had told me about this tool sooner!”
Always enter:
- Every medication name
- Exact dosage
- Quantity per month
- Your preferred pharmacy
The tool then calculates your true annual cost, not just monthly premiums.
📊 Comparing Total Annual Costs, Not Just Premiums
A $0 premium plan in Georgetown (ZIP 29440) might look good, but when you factor in deductibles and copays, it may cost more overall than a $40/month plan. Always add up 12 months of expenses.
🏪 Evaluating Pharmacy Networks and Mail Order Options
- Mail order can save up to 30% on maintenance medications.
- CVS may be “preferred” in Horry County (ZIP 29577), while Walgreens may be cheaper in Sumter (ZIP 29150).
- Always double-check your local pharmacy is in-network as a backup.
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👉 Don’t wait until you’re standing at the pharmacy counter to discover surprises — Palmetto Mutual can help you see your true out-of-pocket costs before you choose a plan.
Tips to Avoid Surprises at the Pharmacy Counter
Your drug coverage should work like a hammock 🏖️ — steady, supportive, and reliable. But many seniors find themselves suddenly “dropping” when prices change without warning.
Story Example 💬
⚠️ The following story is a fictional example based on real-life Medicare situations.
A senior in rural Dillon County (ZIP 29536) thought her maintenance medications would always cost the same. But one spring morning, she went to pick up her blood pressure prescription, and the cost had jumped to $180. With help from an advisor, she found a new Part D plan that kept her costs predictable year-round.
📱 Always Check Coverage Before Filling New Prescriptions
Before heading to the pharmacy in Florence (ZIP 29501) or North Myrtle Beach (ZIP 29582), call your plan or use their online tool/app. This helps you:
- Confirm the medication is covered.
- See if prior authorization is required.
- Avoid surprise denials at the counter.
💳 Understanding Prior Authorization and Step Therapy
- Prior authorization: Your doctor must get approval before the plan covers certain medications.
- Step therapy: You may have to try a lower-cost drug first.
Example: A retiree in Conway (ZIP 29526) couldn’t get her arthritis medication until she tried a generic first — saving her $200 a month once approved.
🏥 What to Do When Your Drug Isn’t Covered
- Request a formulary exception through your plan.
- Ask your doctor if a covered alternative works.
- Check for manufacturer savings programs.
One Ohio retiree appealed a denial for her heart medication — and won. Her bill dropped from $400/month to $40.
Next Steps if Prescription Drug Costs Are Hurting Your Budget
When bills feel overwhelming, many seniors look for quick fixes. But there’s a difference between the shortcut ⚡ and the smart path 🎯.
Shortcut vs. Smart Path Format
⚡ The Shortcut: Switch to all generics immediately
🎯 The Smart Path: Work with your doctor to substitute generics where appropriate while keeping critical brand-name prescriptions
⚡ The Shortcut: Pick the cheapest Part D plan available
🎯 The Smart Path: Calculate your total annual costs — premiums, deductibles, and copays — before choosing
⚡ The Shortcut: Drop Part D to “save” premium costs
🎯 The Smart Path: Stay enrolled to avoid lifetime penalties, and check if you qualify for Extra Help programs
📞 Getting Professional Help to Review Your Options
Licensed Medicare advisors can:
- Compare dozens of plans across ZIPs like Florence (29501), Conway (29526), and Sumter (29150)
- Spot formulary changes that could cost you hundreds
- Help match your plan to your preferred pharmacy (CVS, Walgreens, or local independents)
🗓️ Important Deadlines and Enrollment Periods
⚠️ The following testimonial is a fictional example based on real-life Medicare situations commonly experienced by seniors.
A retiree in Georgetown (ZIP 29440) thought she was stuck with her plan.
“I learned about the Medicare Advantage Open Enrollment Period. I switched in February and immediately saved on prescriptions.”
Key dates to remember:
- Annual Enrollment Period (AEP): Oct 15 – Dec 7
- Medicare Advantage Open Enrollment (MA OEP): Jan 1 – Mar 31
💡 Creating a Medication Budget for 2025
Simple steps to stay ahead:
- Write down all prescriptions, dosages, and refill schedules.
- Use your plan’s cost estimator to project monthly totals.
- Plan for the donut hole stage if you take brand-name or specialty drugs.
A simple spreadsheet can help you track these costs month by month, preventing shocks at the counter.
❓ Frequently Asked Questions
“Hear the Difference Between a Scripted Broker and a Real Conversation”
👵 Senior: “I’m spending hundreds a month on prescriptions — is there anything I can do?”
📞 Broker (scripted): “We’ve got a great plan for you… now let’s get your payment info.”
🤝 Agent (Palmetto Mutual): “Let’s look at your prescriptions, your pharmacy, and your budget first. Then I’ll explain how Part D and MOOP limits work for your situation.”
Get Help Now →📚 Suggested Reading
About the Author
Dvir Mosche is an award-winning independent insurance agent and the founder of Palmetto Mutual, a trusted insurance brokerage specializing in Medicare, final expense, and senior benefits in North and South Carolina and across the country. Since entering the industry in 2017, he has been recognized multiple times as a top agent for his dedication to educating and assisting seniors in finding the proper coverage. His mission is to simplify the process, provide honest and personalized guidance, and ensure that every client gets coverage they can depend on for life.
