By Patricia Prewitt
My Personal Rx Adviser
These past few weeks I have been attending classes by Medicare experts to learn how the upcoming Affordable Care Act (ACA) changes for 2025 will impact out-of-pocket prescription costs for 2025 Medicare prescription plans.
Here are key takeaways I have learned from various seminars:
First: Some insurance companies have chosen to leave states or regional markets. Nationally, there will be about 30% fewer insurance companies offering Medicare coverage and/or Medicare Part D plans. Premium costs are likely to rise, though no more than 6% under the ACA rules.
In Massachusetts, WellCare Advantage will discontinue its Medicare Advantage supplement plan, but will continue to offer a Medicare Part D Rx plan. Aetna, United, and Commonwealth Care have significantly reduced the number of plans offered.
Second: If you are 65 (or will be in 2025), still working, and have employer insurance, it is important to carefully review your employer plan to make sure there is “creditable coverage” for prescriptions. Without credible coverage (as defined by the ACA), future Medicare Med D penalties might be assessed. There are many employer plans, and nuances based on employer size are complicated. It might be that a Medicare election could be a better choice, if you are eligible.
Third: Pay attention to plan notification changes that have arrived by mail! Insurance providers annually change their prescription formularies. Check your medication list for a plan that works best for you. Use www.medicare.gov to compare plans and costs for 2025. If you are not good with a computer, ask a trusted friend or family member to help you. Alternatively, someone at your health center, local library, or senior center might be able to provide assistance.
Now for the good news: For Medicare enrollees, in 2025 the out-of-pocket maximum costs for prescriptions is $2,000. The costs accrued to that $2,000 will be determined by each carrier as it relates to copayments, coinsurance, and deductibles for each plan’s rules. According to estimates, about 1.5 million Medicare enrollees will directly benefit from these changes to the previous “donut hole” gap in coverage. For those with chronic conditions and historically high out-of-pocket costs, this is huge! Note: The monthly premium for your prescription insurance plan is not included in this $2,000.
Coverages and costs are set by each insurance plan. Not every medication will be covered. There may continue to be expenses for certain medications excluded from a plan formulary, or “lifestyle” medications that have high costs.
2025 new budgeting option: Plans may offer a payment option, which spreads the out-of-pocket prescription costs over a 12-month period. Much like setting up a payment plan for an electric bill, this means you pay a fixed amount each month. This avoids the high costs that occur at the beginning of the year, when the annual deductible for your plan resets. For 2025, the maximum prescription deductible is $590, though plans may offer lower deductible choices.
If you are comfortable on a digital device, start with the www.medicare.gov website to compare Rx costs for 2025. Consider reviewing your medications list with a knowledgeable Medicare insurance agent or broker. SHINE counselors at local area senior centers or councils on aging also work by appointment to provide guidance about prescription plans.
Content provided is for educational purposes only, and is not intended as a substitute for advice from a qualified medical professional. The opinions expressed within are those of the author.
About the Author: Patricia Prewitt is a local Massachusetts resident who spent more than 30 years in the pharmaceutical industry. Tricia is a consumer education advocate, and loves helping people find ways to save money on their prescriptions. More information and free resources are available on her website at https://mypersonalrxadvisor.com/resources or call her at 508-507-8840. Favorite Quote: “Act as if what you do makes a difference. It does.” – William James
