By Jose Juarez, Guest columnist
Navigating the complexities of health care can be overwhelming, especially when you’re managing your health, budget and peace of mind. The recent changes to Medicare Part D, the prescription drug coverage program, come after not being changed in nearly 20 years. So, it’s important for you to review your current plans and ensure you don’t end up having to pay more.
Having worked with seniors for many years, I understand how critical it is to have reliable information to make decisions. Before we dive into the recent updates, it’s helpful to revisit what each part of Medicare covers to give you a clearer understanding of how Part D fits into the broader Medicare picture:
- Medicare Part A: This part covers hospital stays, skilled nursing facilities, hospice care and some home health services. Most people do not pay a premium for Part A because they’ve worked and paid Medicare taxes throughout their careers.
- Medicare Part B: Part B covers doctor visits, outpatient services, preventive care, lab tests and medical equipment like walkers and wheelchairs. Most beneficiaries pay a monthly premium for Part B, which is based on their income.
- Medicare Part C (Medicare Advantage): This is an alternative to Original Medicare (Parts A and B). Medicare Advantage plans are offered by private insurers and often include Part D (prescription drug coverage) as well as additional benefits like vision, dental, and hearing coverage.
- Medicare Part D: Part D is the part of Medicare that helps cover the cost of prescription drugs. It’s offered by private insurance companies and is available to anyone who has Medicare. This is the part undergoing important updates that can greatly impact your prescription drug costs.
- Recent changes to Medicare Part D are part of an ongoing effort to make prescription drugs more affordable and accessible. These updates are aimed at easing the financial burden on seniors and ensuring that medications remain within reach.
Below are key changes to note about Medicare Part D.
Capping out-of-pocket costs
This is one of the most anticipated changes, as it helps reduce the financial stress of high medication costs, especially for those who take multiple prescriptions or need expensive medications. You will no longer face unlimited out-of-pocket costs for drugs once you reach the catastrophic coverage phase — out-of-pocket expenses will be capped at approximately $2,000 per year. As a result, this could lead to higher costs for prescription drug plans, which is why evaluating your current coverage is so important.
Medicare drug price negotiations
For the first time, Medicare will be able to negotiate the prices of 15 high-cost drugs directly with manufacturers. These negotiations will primarily focus on drugs that are commonly used by Medicare beneficiaries and have no generic or comparable alternatives. The goal is to lower the cost of these drugs, potentially saving you hundreds or even thousands of dollars per year.
Eliminating the “donut hole” coverage gap
The Medicare “donut hole” coverage gap will be eliminated. Medicare Part D will now have a simplified, three-phase benefit: a deductible phase, an initial coverage phase and a catastrophic phase. The initial coverage phase will extend until your costs reach the $2,000 annual cap. After this, in the catastrophic phase, you will pay $0 for covered medications (within the plan’s formulary).
New drug deductible
Some plans may add a drug deductible as high as $590. Additionally, monthly premium increases will be limited to approximately $2 to help manage health care costs while maintaining access to necessary medications.
Changes in medications formulary and tier levels
High-tier medications may come with increased costs and higher deductibles. It’s important to check your plan’s formulary to understand any changes to your medication coverage, as out-of-formulary drugs will not count toward your $2,000 out-of-pocket maximum.
Other changes
There could be a reduction in benefits, so review the 2025 summary of benefit for your plan’s upcoming changes.
Certain plans, such as UHC’s $42 monthly PPO and Alignment 007 PPO, will no longer be available in 2025, and beneficiaries will be automatically dis-enrolled into traditional Medicare. If you are affected, call me at 877-599-5622 for guidance through this transition.
Some plans, including those from Alignment and Clever, may no longer be accepted by MemorialCare starting Jan. 1. If you want to continue receiving care through MemorialCare, contact me for help navigating your options.
Though choosing a Medicare plan can feel overwhelming, these updates are designed to make healthcare management easier and more affordable, giving you the confidence to make the best decisions for your health and financial well-being. If you need help navigating these changes, please call 877-599-5622 or visit memorialcare.org/MAEP24.
Jose Juarez is a Medicare education specialist for MemorialCare.
