Is it really possible that all Medicare beneficiaries will pay no more than $2,000 out-of-pocket for prescription drugs in 2025? Not exactly. In fact, it is a gray area at best. And the ability to access accurate information as to what drugs are covered under which plans borders on the impossible. Medicare open enrollment began on October 15 and ends on December 7. What can be done?
Every media report highlights a $35 maximum for insulin for diabetics. Undoubtedly, this reduction in insulin costs is important to diabetics. What if you’re not diabetic but face significant other prescription drug costs? There are six “protected” drug classes: immunosuppressant (organ transplant), antiretroviral (HIV/AIDS), antidepressant, antipsychotic, anticonvulsant (seizures), and antineoplastic (cancer). Will all drugs, including specialty drugs be considered eligible for the $2,000 limit? Confused? Me, too!
The Inflation Reduction Act (IRA) also known as the prescription drug law, made several improvements to the basic Part D benefit. Determining how this legislation will apply to me is another story. As a current participant in a Part D plan, the first place I contacted was my existing provider. The patient portal had no 2025 formulary or other 2025 plan information. Customer service for my plan (as well as many others) is offshore and is only able to answer the most basic question. Hope springs eternal, so I called and asked a few simple questions. Not only was could the representative not answer the most basic questions, but I was also told that once I reached the $2,000 limit, I would pay nothing for prescriptions. Not correct.
I moved on. I thought perhaps an entity that offers both online comparisons and comparisons from a registered insurance representative by phone might be an answer. I input my prescription information into the online tool and received two options, both different from what I have now. I was still unclear where the $2,000 limit becomes effective. Perhaps a registered representative could answer my questions. I called the toll free line, added my zip code and spoke to a representative. My first question was to confirm that she was registered to sell insurance in New York. She said she didn’t know and put me on hold for 10 minutes. I waited but was not inclined to enroll in any plan she offered. Back on the line, she said she was registered to sell health insurance in New York. I spent 45 minutes providing my prescriptions in detail. She came back with one plan that didn’t cover all of my prescriptions and was not among the plans I had seen online. When I asked why, she indicated that she was licensed with only one insurance company and that was all she could show me. I was done.
Living in NYC is a challenge when it comes to health care: Medicare, Medicare Advantage (Part C), and Part D. I have until December 7 to choose a plan. Let the games begin. Look for future updates.