Advice from the Apothecary: Understanding Upcoming Insurance Changes

The team at Sadler Hughes Apothecary hopes this season finds everyone healthy and firmly on Santa’s Nice List. As part of the new quarterly “Advice from the Apothecary” feature, the pharmacy will be sharing helpful, easy-to-follow updates about topics that affect everyday life at the pharmacy counter.

For the first installment, the focus is on a topic that impacts nearly every household: insurance. Two significant updates are coming — one related to Medicare, and another for members of the South Carolina State Health Plan (PEBA).

Medicare’s New Drug Price Negotiation Program

Beginning January 1, Medicare is launching an initiative aimed at lowering out-of-pocket costs for some widely used prescription medications. Under this program, Medicare will identify certain high-cost drugs and work directly with manufacturers to establish more affordable, negotiated pricing.

What this means for people with Medicare:

• Some medications included in the program may become more affordable at the pharmacy counter.
• Negotiated prices flow through Medicare Part D plans and are intended to help reduce patient spending throughout the year.
• The program is expected to expand over time as additional medications become eligible for negotiation

State Health Plan (PEBA): Transition from Express Scripts to Caremark

Members of the South Carolina State Health Plan have recently begun receiving information about upcoming changes to their prescription benefit management. Beginning in January 2026, the plan will transition from Express Scripts to Caremark.

Key points for State Plan members:

Copays should remain the same as this year under Caremark.

• Members will still be able to use the pharmacy of their choice.
• The formulary may differ, which could mean that some prescriptions require a new or updated prior authorization.
• Caremark has indicated it will honor active prior authorizations until their expiration date. For example, a one-year authorization approved in August 2025 will remain valid through August 2026.
• As the transition date approaches, patients may find it helpful to check with their pharmacy about refills before January 2026 to ensure they have adequate medication during the changeover.

Have a Topic You’d Like Us to Cover?

The Sadler Hughes team welcomes topic suggestions for future “Advice from the Apothecary” columns. Ideas may be emailed to [email protected].

About Sadler Hughes Apothecary

Founded in 1917, Sadler Hughes Apothecary has proudly served Clinton and Laurens County for more than a century. Built on generations of family leadership, the pharmacy is known for its personalized service, deep community roots, and commitment to caring for every customer by name. As a full-service community pharmacy, Sadler Hughes Apothecary continues its long tradition of providing trusted, attentive care to residents and Presbyterian College students alike.