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Everything Your Customers Need to Know About How Employer-Sponsored Health Plans Compare to Medicare for Prescription Drug Costs

When it comes to prescription drug costs, there can be significant differences between employer-sponsored health plans and Medicare. Understanding the differences between the two can help your clients save money and ensure you help them get the coverage they need. Here’s what your customers need to know about employer-sponsored health plans and Medicare.


Generally speaking, employer-sponsored plans tend to pay more for drugs than Medicare. This is because employers often negotiate discounts with drug manufacturers, allowing them to offer lower drug costs than Medicare.


Employer-sponsored health plans may provide more comprehensive coverage for prescription drugs than Medicare. Some employer-sponsored plans may cover drugs not covered by Medicare.

Out-of-pocket costs: 

While employer-sponsored health plans may pay more for drugs than Medicare, they may also require higher out-of-pocket costs. Employer-sponsored plans may have higher co-pays, coinsurance, and deductibles than Medicare.


Employer-sponsored health plans and Medicare may have different formularies, which are lists of drugs that are covered and excluded. Make sure customers check the formularies for both types of plans before making a decision.

Specialty drugs: 

Many employer-sponsored plans have higher copays and coinsurance for specialty drugs. Medicare, on the other hand, has lower copays and coinsurance for specialty drugs.

Prior authorization: 

Employer-sponsored plans may require prior authorization for certain drugs, while Medicare generally does not.

Step therapy: 

Employer-sponsored health plans may require step therapy for certain drugs, while Medicare does not.

Employer-sponsored health plans and Medicare can have significant differences as far as prescription drug costs. Understanding the differences can help customers make an informed decision about which plan is best for them. Make sure to emphasize to clients that they should compare the cost, coverage, and out-of-pocket expenses for each plan before making a decision.

Your next step as an agent is to learn how Medicare Advantage Plans (MAPD) and Prescription Drug Plans (Part D) play a role in helping your clients control their prescription drug costs. Work with Agility to learn more!

Are you contracted to sell Medicare plans yet? Contact us to get started today!

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