What are the biggest 2025 Medicare Prescription Drug Changes?

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What is covered by the cap

All prescription medications covered by Part D plans are included under this cap, including deductibles, copayments, and coinsurance for covered drugs.

It does not apply to costs for drugs that are not covered under a Part D plan, nor does it cover drugs covered under Medicare Part B, such as injectables and infused drugs.

What does the Part D cap not include?

This cap doesn’t apply to plan premiums or to drugs your Part D plan doesn’t cover. It also does not apply to out-of-pocket spending on Part B drugs. Medicare Part B covers drugs that are administered by a doctor, nurse, or other healthcare provider in an outpatient setting such as a doctor’s office. For example, some cancer drugs and injectable drugs are covered under Part B.

Does the cap affect my Part D premium?

This cap does not apply to the cost of your Part D plan premium. We encourage you to review premium rates while considering a Part D plan as part of open enrollment.

Paying for covered medications

You will continue to pay your out-of-pocket costs for prescription medications through your pharmacy, unless you join the Medicare Prescription Payment Plan.

If you opt-in to the Medicare Prescription Payment Plan—a payment option available through your health plan starting January 1, 2025—you will be billed monthly by your health plan and will pay them directly instead of your pharmacy.

Are any medications excluded from Part D plans?

Part D plans may choose to not cover certain drugs. However, they are required to cover medications that fall into one of the six protected classes: immunosuppressant (organ transplant), antiretroviral (HIV/AIDS), antidepressant, antipsychotic, anticonvulsant (seizures), and antineoplastic (cancer). Drug plans must cover at least two drugs in other categories.

If you are prescribed a drug that is not covered by your prescription drug plan, here are some options:

• If the non-covered prescription drug is a brand-name medication, ask your healthcare provider whether a generic equivalent might work (if there is one).
• Find out whether there are any other prescription drugs in your plan’s formulary that would be effective.
• Your healthcare provider can try a formulary exception, a request to obtain a Part D drug that is not included on a plan’s formulary. If the plan denies the request, there is an appeals process.
• During the Open Enrollment Period, October 15-December 7, evaluate the plans available to you. You might find one that covers your needed medication.

Please note, if you choose to pay for a medication that is not covered by your prescription drug plan, your payment will not apply toward the Part D cap of $2,000.

How will I know when the $2,000 Medicare Part D cap has been met?

Your Part D plan or Medicare Advantage drug plan will be tracking costs and will determine when the cap has been met.