Important Changes Are Coming to Medicare in 2025: What You Need to Know to Help Your Patients
Nicole M. Boschi, PhD, the director of regulatory affairs at the National MS Society, talked about the impact of the upcoming Medicare Part D and Medicare Advantage changes for the multiple sclerosis community.
Nicole M. Boschi, PhD
(Credit: National Multiple Sclerosis Society)
On August 16, 2022, President Biden signed the Inflation Reduction Act (IRA) into law. This landmark legislation aims to address several issues related to healthcare, particularly high prescription drug prices. In addition to giving Medicare the authority to negotiate the price of certain prescription drugs, the IRA established out-of-pocket Medicare Part D cost-sharing limits. Additionally, the IRA gives Part D beneficiaries the option to spread out the cost of their drugs over the course of the calendar year. The National Multiple Sclerosis Society (Society) continually works to increase access to the treatments that those living with MS rely on, including advocating for the passage of the IRA. These new provisions represent the most significant changes in Medicare Part D since the program was established in 2006, and the Society is committed to educating healthcare providers on how to assist individuals affected by multiple sclerosis (MS) to navigate these changes to more affordably access medications that allow them to live their best lives. Here’s what you need to know:
Medicare Part D Negotiated Drugs
No MS therapies were among the ten drugs chosen for the first negotiation cycle, which will become effective in 2026. Like the first 10 drugs, these additional 15 drugs will be limited to Part D drugs. Medicare drug pricing negotiation will expand to Part B in addition to Part D drugs in 2026, with the negotiated prices taking effect in 2028.
Medicare Part D Out-of-Pocket Limits
In 2024, Medicare Part D enrollees' out-of-pocket costs were capped at about $3,300 - $3,800 - when they reached the catastrophic coverage phase. Beginning January 1, 2025, the IRA caps annual out-of-pocket costs for Part D beneficiaries at $2,000. Once an individual reaches this limit, they will pay nothing out-of-pocket for the rest of the year. Please remember that this cap only applies to Part D drugs (oral and self-administered therapies) and not Part B drugs (infused drugs administered by a medical facility). This new out-of-pocket cap could provide a huge relief for many living with MS!
Medicare Prescription Payment Plan (M3P)
One of the provisions of the IRA aimed at reducing the burden of high prescription drug prices on Medicare beneficiaries is the option to spread the cost of their Part D prescription drugs over a calendar year. Enrollment in this program, known as the Medicare Prescription Payment Plan (M3P), is voluntary and may benefit individuals with high out-of-pocket prescription drug costs early in the plan year. Part D beneficiaries need to understand that the M3P is not a discount program, and it will not lower the cost of their drugs, but it will allow them to divide up their costs over a longer period.
Here's how the plan works:
- During Medicare Open Enrollment for the 2025 plan year, an individual’s Part D sponsor will send information about enrolling in the M3P.
- An individual may enroll in the M3P through the following options:
- online through their Part D sponsor’s website
- by mailing in the election request form
- via telephone
- If an individual enrolls in the M3P during open enrollment, beginning January 1, 2025:
- They will pay $0 when picking up a Part D prescription at the pharmacy counter. Instead, their Part D sponsor will send them a bill, dividing their payments up over the remaining months of the plan year. Reminder – total Part D out-of-pocket costs for 2025 cannot exceed $2,000.
- In 2025, individuals will NOT be able to enroll at the pharmacy counter, and pharmacy staff are not obligated to provide M3P counseling.
- An individual can elect to participate in the M3P at any time during the plan year, but for individuals taking more expensive Part D drugs, it is more beneficial to enroll early so payments can be spread over a longer period.
- An individual can also choose to end their participation in the program before the end of the plan year but will still owe the Part D sponsor for any incurred costs.
- Those with traditional Medicare Part D and Medicare Advantage Part D can sign up for the M3P.
Extra Help for Those with Limited Income
- In 2024, the Medicare Part D Low-Income Subsidy (LIS) Extra Help Program was expanded to include Medicare Beneficiaries with incomes up to 150% of the poverty line.
- In 2024, everyone who qualifies for Extra Help will pay:
- $0 for their Medicare Part D premium
- $0 for Medicare plan deductible
- A reduced amount for both generic and brand-name drugs
- Beneficiaries get Extra Help automatically if they receive:
- Full Medicaid coverage
- Help from their state’s Medicare Savings Program
- Supplemental Security Income (SSI) benefits (note: SSI benefits are not the same as Social Security retirement or disability benefits)
The Society will work with providers and individuals living with MS to help them navigate these changes. Be on the lookout for additional learning opportunities.
What Can You Do?
- Encourage patients to review their options during open enrollment and find a Part D plan that best suits their needs.
- When prescribing high-priced Part D DMT drugs to Medicare beneficiaries, educate them on the $2,000 out-of-pocket cap and make them aware of the M3P.
- Offer educational materials in your office on the changes to Medicare.
- National MS Society MS Navigator: https://www.nationalmssociety.org/resources/get-support/ms-navigator
800-344-4867, 7 a.m. to 5 p.m. MT (M-F)
More Resources
