Reminder: Check Your 2025 Medicare Drug Plans—You Have Until December 7 to Change
Plus 2025 Medicare drug plan changes to expect
November 30, 2024
- Summary: You have until December 7 to check and make changes in your Medicare Drug Plans
- Reading time: 4–5 minutes.
Will your Medicare drug plan cover your medications next year? It’s worth checking one last time before the December 7 enrollment deadline.
We hear about formulary changes every year, especially among anticoagulants (blood thinners) and antiarrhythmic drugs. Some formularies stop covering medications that have been covered for years.
If your plan drops your medications from the formulary, it could be costly to you. You may have to pay 100% or be forced to switch medications, which is called “non-medical switching.” That means your insurance plan forced you to change medications rather than you or your doctor deciding on that. If you’re stable on your medications and they work well for you, having to switch could harm your health. Insurance companies should not play doctor, changing your doctor’s decisions.
If you discover that an important medication has been removed from your plan’s formulary, you still have time to make 2025 Medicare coverage changes before December 7.
How to Check for Formulary Changes
You can check your medication coverage by downloading your plan’s formulary from their website.
Alternatively, Medicare’s Plan Finder makes it easy to check online, too, especially if you log in and your medications are already listed. It will show what your plan will cost and what it will cover next year.
If any of your medications have been dropped, the Plan Finder can help you find plans that cover them.
Enter your location, medications, doses, and preferred pharmacies to find drug plans in your area in the Plan Finder. You’ll find cost information for plans and medications and can compare plans side-by-side.
You can drill deeper into the drug plans to see detailed breakdowns of costs for each medication by pharmacy.
This should make it easy to check medication coverage for next year.
If you need to change plans, it makes learning about your options easy and even helps you enroll in a new plan.
You have until December 7, but it will be here before we know it. Use this link to access the Medicare Plan Finder.
Changes for 2025
The first change in 2025 is a $2,000 cap on Medicare out-of-pocket spending for drugs. This applies to Part D drug plans and Medicare Advantage drug plans.
It is important to note that this cap applies only to Covered Medications. If your medication is not on your plan’s formulary, the cap does not apply and you could pay significantly more for medications.
This becomes concerning because insurance companies and PBMs (pharmacy benefit managers) will have to pay more for your medications. Thus, they may decide to play games with us and remove costly medications from the formulary to encourage you to take cheaper drugs, which may not work for you.
If this happens, you and your doctor can submit a Prior Authorization request. If it is turned down and you choose to pay for the medication yourself, it is not considered a covered medication and the $2,000 cap does not apply.
The second change for 2025 is often referred to as “smoothing.” The formal name is the Medicare Prescription Payment Plan (M3P).
If you have an expensive prescription to pick up early in the year, the pharmacist should notify you that you can spread the payments out over a number of months. To do so, you have to enroll directly with your insurance plan before picking up your prescription. If you’re going to pick up an expensive prescription, you may be able to save steps by contacting your insurance company first to enroll in the plan.
In 2026, you should be able to enroll directly at the pharmacy when you pick up your medication.
The full details of the M3P can be found at the Medicare Prescription Payment Plan page.
Future Changes
In 2026, the negotiated prices will go into effect for the ten medications that Medicare negotiated with the manufacturers. Medicare refers to them as Maximum Fair Prices (MFPs), but others refer to them as government-set prices as there really wasn’t any negotiating involved. If the price Medicare decided to pay was not agreed to, the manufacturer’s drugs would be removed from Medicare, which is not a negotiation.
Note that these MFPs are the prices Medicare will pay; these are not the prices we will pay. We could actually end up paying more because we anticipate that the PBMs will play games with us to decrease the financial hit this will cause them since they will no longer get rebates from the manufacturers of these 10 medications.
In the summer of 2023, the Government Accountability Office reported that the Medicare drug plan insurers and PBMs paid less for highly rebated drugs than the Medicare beneficiaries did and recommended that Medicare monitor the effect of rebates, especially with the Inflation Reduction Act.
PBMs are unlikely to take the financial hit with the negotiated medications lightly. We can expect them to adjust co-pays and tiers, drop medications from formularies, and use non-medical switching and prior authorizations to deny us access to vital lifesaving medications.
My concerns prompted me to write an op-ed, Government Just Set Prices on 10 Medicare Drugs: That Doesn’t Mean Patients Will Win. It was published recently at RealClearHealth and spotlighted how the Inflation Reduction Act could incentivize the use of burdensome PBM practices that put provider-recommended treatments out of reach for patients.