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It is open enrollment season for Medicare Part D, and the patient-led advocacy coalition MAPRx is helping patients get the coverage they need.
Open enrollment runs Oct. 15 through Dec. 7 for plans starting on Jan. 1, 2025. With all of the changes to Medicare Part D as a result of the Inflation Reduction Act (IRA), MAPRx has expanded its resources to meet expected needs. MAPRx is a coalition of more than 60 patient groups “guided by the idea that every Medicare Part D beneficiary should have timely, affordable access to the medications they need to live a healthy life,” per their mission.
“We’ve really expanded the educational resources we’re providing,” explains Pat Wildman, Senior Vice President, Advocacy & Government Relations at the Lupus Foundation of America, which convenes the MAPRx coalition.
The coalition’s new Open Enrollment Guide “is aimed at helping beneficiaries review their plan options because their Part D plan in 2025 may look different than it did in 2024 as a result of changes made by the IRA. Those changes include important new benefits, such as the Medicare Prescription Payment Plan and a $2,000 out-of-pocket (OOP) cap. However, other changes may restrict access to needed medications as plans may have more narrow formulates and increase utilization management practices such as prior authorization and step therapy.”
“People need to be aware of these changes so that they can make informed decisions during open enrollment and choose the plan that meets their medication needs. What may have worked last year may not work this year,” continued Wildman.
The Lupus Foundation of America established the MAPRx coalition in 2005 when Medicare Part D was created. Today, the coalition includes more than 60 national patient and family caregiver organizations. The coalition works to protect and strengthen Medicare Part D so that beneficiaries continue to have timely access to the medications they need. MAPRx regularly engages policymakers, hosts briefings, and develops reports on key Part D issues while at the same time producing materials that empower beneficiaries and educate the broader stakeholder community.
MAPRx’s resources are both comprehensive and easy to navigate. As beneficiaries start the 2025 enrollment process, here are a few of the top things to know.
All plans are changing in 2025
One important reason for patients to revisit their plans during Medicare Part D open enrollment is that all plans will change in 2025.
“Use this Annual Open Enrollment Period to compare plans and find the plan that best meets your prescription drug needs at a cost you can afford,” says MAPRx.
Changes to things like monthly premiums, annual deductibles, co-payment or coinsurance, and plan formularies are all possibilities. Additionally, there may also be changes to coverage policies that may restrict access to certain drugs. For example, some drugs may now require prior authorization by a patient’s doctor. Other plans may implement step therapy, which requires doctors to prescribe a cheaper option in the same class of drug before going to the doctor’s original prescription. There is also the risk of certain plans implementing quantity limits.
And some plans may decide not to participate in 2025 at all.
While patients should have received a notice of plan changes or cancelation, MAPRx resources help patients better understand what has changed and what things to look out for as they review their options
Some IRA measures are already in effect, others will be in 2025
One goal of the IRA was to make Medicare Part D medications more affordable for patients. While a few of these measures have already taken effect, others will not happen until 2025.
Already, there are $0 out-of-pocket (OOP) costs for vaccines under Part D, and insulin copay costs have been capped monthly at $35. These two very popular measures were strongly supported by both patients and the biotech industry.
Additionally, eligibility has expanded for the Extra Help program, which aims to help people with limited income reduce OOP expenses, and may allow people with Medicare to qualify for even more savings.
Some of the more complex provisions of the IRA go into effect in 2025 and can change from person to person, depending on their circumstances.
First, the annual OOP cap for Part D drugs will go into effect and limit patient cost to $2,000. After patients hit the out-of-pocket cap, they will pay $0 for their prescription drugs for the rest of the year. However, this cap only covers drugs on a plan’s formulary. If a drug is not covered, patients must pay the full cost, and the money patients pay for these drugs does not count toward the $2,000 out-of-pocket maximum.
“That is why it is important to make sure that your drugs, especially the most expensive ones, are on the formulary of the plan you select,” writes MAPRx. “You, your authorized representative or your doctor can ask for a ‘coverage determination’ (exception) to get your plan to cover a drug when it is not on the plan’s formulary.”
In addition, the IRA “smoothing” measures will be implemented. The Medicare Prescription Payment Plan (MPPP) aims to smooth out the burden of drug costs by allowing patients to spread out their payments for prescriptions over the year rather than paying the full cost when they pick them up at the pharmacy—with zero-interest monthly payments.
Is MPPP right for you?
As MPPP is one of the newest (and more complicated) measures, MAPRx is doing a large amount of education about it to help patients fully understand the process going into 2025.
For example, many patients may not be certain if MPPP is right for them. MAPRx explains that if a patient is worried about high monthly prescription drug costs, has trouble paying out-of-pocket costs up front, or prefers to spread out payments over the year, smoothing may be the right choice.
Importantly, patients need to understand that if they sign up for MPPP, when they fill a prescription, they won’t have to pay at the pharmacy counter.
“Instead,” explains MAPRx, “you will get a monthly bill from your Part D plan with information on how much you incur for that specific month and your remaining balance for the year. This will be a different document from your Part D plan premium bill and Part D Explanation of Benefits document.”
There are also provisions in the plan for missed or late payments. If a patient misses a payment under MPPP, their plan must inform them with a notice a couple of weeks after a missed payment. Additionally, all plans must give a two-month leeway period for missed payments.
“If the balance is paid during this time, you can continue participating in the MPPP,” writes MAPRx. “However, if you do not make the payment within the 2-month timeframe, your plan can remove you from the MPPP. However, missing a prescription drug payment will not impact your Part D plan coverage. The only way you can be removed from your Part D plan is if you miss your monthly premiums.”
Patients can opt out of the MPPP at any time, but any outstanding balances must be paid when a patient leaves.
“The IRA made some of the most significant changes to Medicare Part D since the program was created,” said Wildman. “Therefore, it is critically important that beneficiaries review their options to ensure that they have access to the medications they need, when they need them. MAPRx is pleased to provide resources that can help beneficiaries navigate the 2025 Part D open enrollment.”
Open enrollment season can be overwhelming, but resources are available for patients across the country. For more information, visit maprx.info and check out MAPRx’s member list to find a patient organization that can help you determine what’s best for you and your family.
