If you’re over 65 or close to turning 65, you have likely been inundated with mail from insurance companies trying to get you to sign up for their Medicare offerings as open enrollment kicks off on October 15.
It’s confusing. Some insurance companies invite would-be subscribers to a free lunch to make their pitch, while others place numerous ads on television, radio, and online.
Somehow, the consumer must figure it all out—but it’s worth your time to do so. There’s a lot to know, including changes such as a $2,000 cap on Part D drug costs for those with traditional Medicare, extending to those with Advantage plans in 2025.
“You’ll be seeing a lot of publicity and promotion about that,” said Cheryl Harris, SHINE (Serving Health Insurance Needs for Elders) liaison for Elder Options, a Gainesville-based not-for-profit organization that provides resources and assistance to seniors. “That is huge, but people must remember that the cap only applies to medications on the formulary with your plan.”
Formulary is a critical concept to master. Most Medicare drug plans have a list of covered drugs that include brand-name prescription and generic drug coverage and generally include at least two drugs in the most prescribed categories and classes.
“The list of covered medications varies from prescription drug plan to prescription drug plan and can vary from year to year,” Harris said. “That is why reviewing your plan for changes annually is important.”
But while the $2,000 cap on drug costs is getting the most attention, other changes are coming up for 2025, including the implementation of drug payment plans and programs to assist those caring for family members with dementia.
Negotiators for the Centers for Medicare and Medicaid Services are negotiating a ceiling for 10 expensive, popular drugs for Medicare beneficiaries. These include Eliquis, Jardiance, Xarelto, Januvia, Farxiga, Entresto, Enbrel, Inbruvica, and Stelara, and versions of diabetes drugs Flasp and NovoLog.
Last year, Medicare capped covered insulin costs at $35 a month and eliminated out-of-pocket costs for recommended vaccines.
However, Harris points out some concerns, like the drop in drug plans from 20 to 14 for 2025 in our local area, although she notes a zero-premium plan will still be available.
That’s one reason Medicare beneficiaries should take time to shop around when signing up for 2025 coverage, a step people often fail to take. KFF, an independent source for health policy research, polling and news, found that more than two-thirds of Medicare beneficiaries did not compare plans in 2022.
“It’s a decision that could have a significant impact on enrollees’ coverage and costs,” KFF wrote.
Harris agrees and encourages her clients to compare and consider all the options. She believes the upcoming Medicare Prescription Payment Plan will be helpful to people who have high deductibles since they can budget payments for their drugs over the year.
“It will allow you to enroll with your prescription drug plan, and then they will divide payment of medication over 12 months. But you must enroll in the Medicare prescription payment plan through your drug plan,” she said. “Our role as SHINE counselors is to educate people about things like this.”
Another new benefit is the program providing services under the Guiding an Improved Dementia Experience (GUIDE). This program offers support services, a care navigator, caregiver training and up to $2,500 to compensate caregivers. Participants must be enrolled in original Medicare and have a dementia diagnosis. They can’t be in hospice or a nursing home.
Harris said two providers in the area offer services under the GUIDE model in Ocala and Leesburg.
“Although this program is expanding in the United States, there does not appear to be wide acceptance in our area,” Harris said.
SHINE has five paid staff and 60 certified SHINE volunteers to cover Elder Options’ 16-county service area, which includes Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee and Union counties.
The Medicare open enrollment period continues through Dec. 7.
