By Niki Salomon, Pharm D

Medicare Part D beneficiaries will experience significant updates to their prescription drug coverage in 2025. One of the most notable changes is a new $2,000 cap on out-of-pocket expenses for prescription drugs, a significant reduction from the previous $8,000 cap in 2024. Additionally, some plans may require a deductible, with a maximum of $590, while monthly premiums can vary widely, ranging from $0 to nearly $120, depending on the specific plan. It’s beneficial for all Medicare D patients to analyze their plan annually since coverage, preferred pharmacies, and co-pays vary each year. Assuming your plan from 2024 will be best in 2025 is not a safe strategy.

Another major update is the elimination of the “donut hole” or coverage gap, which previously left some beneficiaries paying higher out-of-pocket costs after reaching a certain threshold. Now, coverage will be consistent throughout the year. A new Medicare Prescription Payment Plan is also available, allowing enrollees to spread out drug costs over the year. Instead of paying at the pharmacy, beneficiaries will receive a bill from their drug plan. More details about this payment plan can be found on Medicare’s website.

Insulin will continue to have a cap of $35 for a one-month supply of each Part-D covered insulin, with no deductible applied. Additionally, patients who qualify for both Medicare and Medicaid, known as Dual Eligibility, are encouraged to visit their pharmacy to find the Medicare Part D plan that best meets their needs.

For those enrolling in a Medicare plan, it’s important to consider a few factors. If specific drugs are needed, it’s wise to choose a plan that includes them in its formulary. New Medicare beneficiaries have a six-month window to enroll, starting three months before and ending three months after qualifying and late enrollees may face a penalty. The Extra Help program is available for individuals with limited income, which can reduce premiums and deductibles to $0. Annual income limits are $22,590 for individuals and $30,660 for married couples, and a Medicare Advisor can help those that qualify apply online. 

Medicare Part D options can be reviewed with the help of several resources. Local pharmacies can conduct analyses of current medications and recommend the best plans. Another great local option is Nebraska SHIP specialist Susan Anderson at the Gothenburg Senior Center, who is available by appointment only. For additional support, Medicare or health insurance advisors, such as Will Rahjes at Flatwater Bank or Mike Messersmith at Dayspring Bank, can offer personalized assistance. Information is also available on Medicare’s official website, although it’s a good idea to verify details with a preferred pharmacy to ensure accuracy.

The deadline to enroll in a 2025 Medicare drug plan is Dec. 7, 2024.