Patients will ask about changes coming to Medicare Part D in 2025...as open enrollment occurs from October 15 to December 7.
Explain the biggest difference next year is that the annual out-of-pocket cost will be capped at $2,000. And the new Medicare Prescription Payment Plan gives patients the option to pay these costs monthly to the plan...INSTEAD of all at once at the pharmacy.
But point out that the maximum annual deductible for Part D plans will increase to $590...up from $545 in 2024. And the average basic monthly premium will increase by a few dollars.
Clarify that there will continue to be no out-of-pocket costs for CDC-recommended vaccines covered by Part D (RSV, shingles, Tdap, etc). And co-pays for covered insulin Rxs will still be $35/month max.
Medicare will also now be able to negotiate prices for 10 selected high-cost drugs...such as Eliquis, Januvia, and Xarelto. But these prices won’t take effect until January 1, 2026.
Encourage patients to explore Part D plan options for 2025 during open enrollment. Keep in mind, pharmacy staff CANNOT recommend a plan or enroll patients...but you can help them understand choices.
Provide a current med list to patients...to tailor plan selection. Suggest resources such as the Medicare Plan Finder website (medicare.gov) or 800-MEDICARE...to see costs when comparing plans.
Advise looking at ALL aspects of a plan...co-pays, medication restrictions, pharmacy networks, Star Ratings, etc. A less expensive premium or using an “out-of-network” pharmacy may mean higher co-pays.
Tell people who are happy with their current plan that they don’t need to do anything to reenroll. But still recommend comparing plans...since the best choice for 2024 may not be the best for 2025.
Be aware of other Medicare changes that may impact your patients. For example, HIV/AIDS has been added to the list of core conditions that Part D plans must use to identify patients for MTM services.
And it’s anticipated that meds for HIV pre-exposure prophylaxis (PrEP) will soon be billed under Medicare Part B...instead of Part D. But antivirals for HIV treatment will still be billed under Part D.
Check indications or help obtain diagnosis codes...since some HIV meds (Descovy, Truvada, etc) can be used for prevention OR treatment.
Share our resource, Billing Rx Drugs, with your techs for more insights on Medicare Part B, Part D, and Advantage plans.
- Centers for Medicare & Medicaid Services (CMS). Part D Improvements. August 2024. https://www.cms.gov/inflation-reduction-act-and-medicare/part-d-improvements (Accessed August 10, 2024).
- Centers for Medicare & Medicaid Services (CMS). PrEP for HIV & Related Preventive Services. August 2024. https://www.cms.gov/medicare/coverage/prep (Accessed August 15, 2024).
- Centers for Medicare & Medicaid Services (CMS). CMS Releases 2025 Medicare Part D Bid Information and Announces Premium Stabilization Demonstration. July 2024. https://www.cms.gov/newsroom/fact-sheets/cms-releases-2025-medicare-part-d-bid-information-and-announces-premium-stabilization-demonstration (Accessed August 13, 2024).
- Technician Tutorial: Billing Rx Drugs
- Chart: Preventing RSV
- FAQ: Shingles Vaccine: FAQs
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Checklist:
HIV Pre-Exposure Prophylaxis (PrEP)