There is good news for Medicare recipients in 2024 who count on costly prescriptions. The Inflation Reduction Act passed in 2022 puts an annual ceiling of $3,300 in 2024 for Part D drugs. The number could shift slightly depending on whether they take brand-name or generic medications.
In 2025, the news is even better: the cap changes to a flat $2,000.
Here’s how it worked: people who pay for their medications through Medicare Plan D, the government insurance plan covering most prescription drugs, paid thousands for medications until they reach what’s known as the “catastrophic zone of spending.” After that, they pay a 5% deductible for the rest of the year, often in the thousands.
In 2024, the IRA eliminates the 5% coinsurance. And once patients spend roughly $3,300, they have met the “catastrophic zone.” And they won’t have to pay any more out of pocket for Part D drugs.
Here’s an example of the new rules. Let’s say a 69-year-old man has a plan with a $505 deductible. He takes a blood cancer drug that costs $200,000 per year—roughly $16,600 monthly. In 2023, he pays his full deductible, plus 25% coinsurance, until he hits the $3,100 catastrophic limit for 2023, plus 5% coinsurance after. On his next refill, as he has remained in the catastrophic zone, he paid only the 5% deductible–roughly $830. He’ll pay about $830 every time he fills his prescription, spending more than $12,000 out of pocket for the year.
In 2024, the same man taking the same drug will save a few hundred dollars the first time he fills the prescription, topping out at around $3,300. Subsequent refills will cost nothing. He will not pay for the blood cancer drug, or any other drug, for the year. In 2025, his first trip to the pharmacy will cost him $2,000, the cap for the year, unless he wants to participate in a “cost-smoothing” program and spread the $2,000 over 12 months.
The Inflation Reduction Act lets Medicare officials negotiate the price of drugs. By doing away with the 5% coinsurance, the law forces insurers and drugmakers to pick up part of the tab. Part D covers most outpatient prescription drugs, although some medications, including physician-administered infusions, are covered under Part B.
The downside is that premiums may go up, and Part D paperwork may become more complex. Premiums for stand-alone Part D plans were up an average of 20% in 2023. Because Part D plans are paying for more medications, they may be motivated to use techniques pushing patients to less expensive drugs or requiring them to get insurers’ approval before filling prescriptions. They may also change the list of drugs covered.
It’s always important for Medicare recipients to check their plans and medications, but these changes make it even more important.
Reference: The Wall Street Journal, January 15, 2024, “Medicare Patients on Pricey Drugs Are Saving Big This Year”