How Is the Medicare Part D Benefit Changing in 2025?

Changes in 2025 include a new $2,000 out-of-pocket spending cap, signaling the end of the coverage gap phase. This will include a change in the plan stages from Deductible, Inisital, Coverage Gap and Catastrophic stages to having only the Deductible, Initial and Catastrophic stages.

Out-of-pocket drug spending will be capped at $2,000

Beginning in 2025, Part D enrollees’ out-of-pocket drug costs will be capped at $2,000. This amount will be indexed to rise each year after 2025.

The coverage gap phase will be eliminated

In the initial Part D benefit design, during the coverage gap phase Part D enrollees faced paying 100% of their total drug costs. In 2024, Part D enrollees pay 25% of costs for brand and generic drugs during the coverage gap phase. This phase will be eliminated in 2025. This means that, in 2025, Part D enrollees will no longer face an increase in their cost sharing for a given drug when they move from the initial coverage phase to the catastrophic phase. The cost for Part D drugs will be $0 after the $2,000 Out of Pocket threshold is met.

What Other Changes Are Being Made to Part D?

• As of 2023, the out-of-pocket cost of insulin products is limited to no more than $35 per month in all Part D plans. In addition, adult vaccines covered under Part D, such as the shingles vaccine, are covered with no cost sharing.

• Beginning in 2024 the partial Extra Help/LIS plan was eliminated. Now individuals who have incomes and resources below 150% of the Federal Poverty Level are eligible for full benefits in the Extra Help program.

• Starting in 2025, Part D enrollees will have the option of spreading out their out-of-pocket costs over the year rather than face high out-of-pocket costs in any given month. Enrollees can opt-in to this program by calling their Part D plan sponsor.

This was adapted from an article at kff.com

This article is for information only and should not be considered a recommendation. Talk with a licensed Health Insurance Professional about your specific circumstances. For more information you can go to The Texas Department of Insurance.