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Key Takeaways for MS Providers Regarding Major Medicare Changes Expected in 2025
Sarah Anderson, PharmD, NBC-HWC, senior director of clinical resources and programming at National MS Society, talked about the significant updates under the Inflation Reduction Act to come in 2025 for patients with multiple sclerosis.
Sarah Anderson, PharmD, NBC-HWC
(Credit: PharmToTable)
The Inflation Reduction Act (IRA), signed into law in August 2022, introduced pivotal reforms aimed at addressing high prescription drug costs, particularly for Medicare beneficiaries. Among the key provisions, the IRA granted Medicare the authority to negotiate prices for select drugs and places a cap on out-of-pocket expenses for Medicare Part D. It also offered beneficiaries the option to spread their drug costs over the calendar year. These reforms represent the most significant updates to Medicare Part D since its inception in 2006, as highlighted by Nicole M. Boschi, PhD, in a recent post on NeurologyLive®.
Boschi, the director of regulatory affairs at the National MS Society, emphasized in the blog that the Society's ongoing commitment to improving treatment access for patients with multiple sclerosis (MS), including its advocacy for the IRA. In her post, she noted the Society's dedication to supporting healthcare providers in helping patients with MS navigate these changes, which aim to make medications more affordable and improve patient quality of life. Thus, clinicians serving patients on Medicare Part D or Medicare Advantage plans should be aware of the significant changes taking effect in 2025.
In a recent interview with NeurologyLive, Sarah Anderson, PharmD, NBC-HWC, senior director of clinical resources and programming at the Society, recently explained how these changes will enhance affordability for patients with high prescription drug costs. In the conversation, Anderson also outlined the benefits of the new Medicare Prescription Payment Plan and provided guidance on how clinicians can help their patients enroll in and manage this new option.
NeurologyLive: Can you give us some background regarding the important changes coming to Medicare in 2025? What is changing from 2024?
(Credit: National MS Society)
Sarah Anderson, PharmD, NBC-HWC: These changes relate back to the IRA which is one of the most consequential healthcare laws since the Affordable Care Act was signed into law, and the biggest improvement to Medicare since the passage of Medicare Part D in 2003. 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. 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!
What does the new Medicare Prescription Payment Plan look like?
Beginning in January of 2025, all Medicare prescription drug plans (Medicare Part D plans)—including both standalone Medicare prescription drug plans and Medicare Advantage plans with prescription drug coverage—must offer Part D enrollees the option to pay out-of-pocket prescription drug costs in the form of monthly payments instead of all at once at the pharmacy upon receiving a prescription. This program is called the Medicare Prescription Payment Plan.
Which of your patients will benefit most from this new plan?
The program will be helpful for individuals with high prescription drug costs earlier in the plan year by spreading out those expenses over the course of the plan year.
Do individuals need to opt-in to this plan?
Yes. This is an optional program. Medicare Part D enrollees can opt into the Medicare Prescription Payment Plan during Medicare Open Enrollment which is Oct 15-Dec 7, or throughout the plan year.
Is this a medication discount program?
No. This is not a medication discount program. Instead, it helps enrollees by allowing them to spread out the cost of their Part D prescriptions over a longer period of time. Depending on personal circumstances, this program may or may not be beneficial.
How do individuals enroll in the Medicare Prescription Payment plan?
An individual can enroll via the following options:
- Online through their Part D sponsor’s website
- By mailing in the election request form
- or telephone
How will the medication payment process work for Part D medications if an individual chooses to enroll in the Medicare Prescription Payment Plan?
Participants will be able to pick the date for their payments and will be able to pay by credit card, debit card, electronic fund transfer (EFT) or check
Will individuals be able to enroll in the plan at their local pharmacy?
No. In 2025, individuals will NOT be able to enroll at the pharmacy counter, and pharmacy staff are not obligated to provide counseling on this plan either. An individual can elect to participate in the plan 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. Enrollees have the ability to start, stop and restart the plan through the end of the plan year. An individual can also choose to end their participation in the plan before the end of the plan year but will still owe the Part D sponsor for any incurred costs.
Can you give us an example of how the plan might work?
Here is an example of how the plan might work:
- An individual reaches the $2000 maximum out-of-pocket in January
- The individual pays $166.67 per month instead of $2000 upfront
- The first month’s payment is calculated by dividing the maximum out-of-pocket by 12 months
- Subsequent payments are recalculated each month based on the remaining months in the year and the unpaid balance.
What resource can healthcare providers point their patients to, should their patients come to them with questions on this topic?
Encourage them to contact the Society’s Navigators for assistance in reviewing their plan options during the annual Medicare open enrollment period.
- By phone at 800-344-4867
- By email at contactusnmss@nmss.org
- Or visit our website at nationalMSsociety.org/navigator
Additional resources for healthcare professionals to learn more about the Medicare Prescription Payment Plan can be found here:
