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There are some Medicare Part D changes 2025 coming to (MAPD/PDP) plans.  One of the biggest changes is the discontinuation of the Medicare donut hole in 2025.  In January 2024, CMS released a draft of the new Medicare Part D payment policies.

Click here to get more details on the changes coming to prescription drug coverage in 2025

Key points

Removal of the Donut Hole/Gap phase – The coverage gap phase will merge with the former initial coverage phase. This phase will become the “Standard Coverage Phase”.

There will only be 3 coverage phases. They are Deductible, Standard & Catastrophic.

The Out of Pocket (OOP) threshold for each beneficiary is dropping to $2,000 annually.

The end of the Donut Hole/Gap discount program (CGDP) will place more emphasis on the Manufacturer Discount Program. There will be changes to the drugs that are discounted and how they count towards the OOP.  This also changes who is responsible for the cost of the drugs beyond a set amount.

Watch a YouTube video on Medicare Part D changes

The drug plans will pay similar amounts as in previous years, although a larger part of their responsibility starts much earlier than in previous years.  In other words, drug plans will pay more money on more enrollees overall.

Click here to learn all the details of the Medicare Part D redesign

The new design for prescription coverage consists of three phases of coverage.

1. The first phase is the “Annual Deductible Phase”.  In this phase enrollees pay 100% of their prescription drug cost until they meet the deductible of $590.
2. The second phase is the initial coverage or “Standard Coverage Phase”.  This phase was formerly the initial coverage phase merged with the Donut Hole/Gap phase. During this phase, after the enrollee meets the spending threshold (OOP) of $2,000 for CY 2025, they complete this phase and move into the catastrophic phase.
3. The third phase is the “Catastrophic Phase”. During this coverage phase, the enrollee does not pay any cost sharing for covered Part D drugs.

Learn about the CMS 2025 proposed rule

It is very likely the added costs drug companies incur will result in either higher Part D plan premiums as well as changes to MAPD plan benefits and/or costs.

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Medicare donut hole 2025

There are some big changes coming to Medicare Part D (PDP) plans.  This includes the discontinuation of the Medicare donut hole 2025.  In January 2024, CMS released a draft of the Medicare Part D payment policies.

Starting next year, see what changes are being made to Part D (prescription drug) coverage.

The new design for prescription coverage will consist of three phases of coverage.

1. The first phase will be the “Annual Deductible Phase”.  In this phase the enrollee pays 100% of their prescription drug cost until they meet the deductible of $590.
2. The second phase is the initial coverage or “Standard Coverage Phase”.  This phase is the former initial coverage phase merged with the Donut Hole/Gap phase. During this phase.  Once the enrollee meets the spending threshold(OOP) of $2,000 for CY 2025, they complete this phase of overage and move into the catastrophic phase.
3. The third phase is the catastrophic phase. During this phase of coverage, the enrollee pays no cost sharing for covered Part D drugs.

As you can see, there is no donut hole (coverage gap) phase.  It is merged with the “Standard Coverage Phase”.

Find out about the 2025 Medicare Drug cap

The changes in payment liability

This new plan design includes changes in payment liability of enrollees, plan sponsors, drug manufacturers and CMS.

1. As stated above, in the first phase “Annual Deductible Phase”, the enrollee must pay 100% of the cost for prescription drugs until the deductible amount is met.
2. In the second phase initial coverage “Standard Coverage Phase” enrollees pay 25% coinsurance for covered drugs while the plan sponsor typically pays 65% for  applicable drugs and 75% for all other covered Part D drugs.  Manufacturers usually pay 10% of the cost through the discount program.
3. The third phase “Catastrophic Phase”, enrollees do not pay a cost share for covered Part D drugs.  Drug plan sponsors normally pay 60% of the cost on covered drugs.  Manufacturers pay a discount of about 20% and CMS pays a subsidy equal to 20% of the cost for applicable drugs.  CMS pays about 40% of drug costs for some other Part D drugs.

Click here to learn more about PDP plans

Key points

1. Removal of the Donut Hole/Gap phase – Merging together with the former initial coverage phase now the “Standard Coverage Phase”.
2. There are now only 3 coverage phases: Deductible, Standard & Catastrophic.
3.  The Out of Pocket (OOP) threshold is dropping to $2,000 annually.
4. The end of the Donut Hole/Gap discount program (CGDP) and the start of the Manufacturer Discount Program (Discount Program)changes what drugs get discounts and how they count towards the OOP.  This also changes who is responsible for the cost beyond a set amount.

Watch a YouTube video on Medicare Part D changes

The drug plans will pay similar amounts as in previous years, although a larger part of their responsibility starts much earlier than in previous years.  In other words, drug plans will pay more money on more enrollees overall.

Click here to learn all the details of the Medicare Part D redesign

It is expected that the added costs drug companies incur may result in either higher Part D plan premiums or possibly spread across other MAPD plan costs.

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Extra Help income limits 2024

Medicare Extra Help is a federal program put in place to help individuals whose income and financial resources are limited.  It provides help for those who qualify to pay the costs of their Medicare prescription drugs. The subsidies provided by this program cover premiums, deductibles, as well as co-pays for the costs of Medicare prescription drug plans (Part D).  To qualify for this program, individuals must meet the income criteria set by the federal government each year.  In this post, we will go over the Extra Help income limits 2024.

How to Qualify for Extra Help

1.  Be a U.S. citizen or legal resident

To enroll in Original Medicare, individuals must either be a United States citizen or a legal resident for at least 5 years. In turn, to enroll in Medicare’s Extra Help program, an individual must qualify for Medicare.

Extra Help is crucial for individuals who require assistance with the costs of prescription drugs. Understanding the requirements is the first step to finding the necessary help to ensure the needed coverage is received.

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Vaccines covered by Medicare

Medicare prescription drug plans cover wide variety of prescription drugs, this includes several vaccines covered by Medicare.  Medicare covers vaccines in more than one way; either by Part D  or by Part B (medical coverage) or Part C MA/MAPD plans that may provide coverage for all the parts of Medicare.  It all depends on the type of vaccination and what facility the patient receives it at. As of January 2023, all vaccines covered by Medicare should be free to beneficiaries. This means they should not have any cost-sharing such as; co-pays, co-insurance or deductibles.

Find out about Medicare Part D enrollment periods

Part B covers vaccine coverage

In many cases, if the vaccination is part of a treatment for an illness or injury, it is usually covered by Part B.  In other words, if a beneficiary gets a puncture wound, they may need a tetanus shot. When this is the case, the vaccination falls under Medicare Part B coverage (Part C, if they have an MA/MAPD plan).  If the beneficiary opts to receive a tetanus booster shot, that charge falls under their Part D plan.

Watch a quick YouTube video on enrollment periods including Part B late enrollment

Here are some common vaccines that Part B covers:

*Flu

*Covid 19

*Pneumonia

*Hepatitis B – in cases where the individual is at high to intermediate risk.

*Some necessary vaccines needed to treat an injury, illness or exposure to a disease.

Part B covers some drugs

In some instances, Part B covers drugs beneficiaries do not normally give themselves.  In other words drugs that you receive either in a doctor’s office or in an outpatient hospital setting.

A few of the drugs covered by Part B

Part D vaccine coverage

Part D Vaccines are provided in an effort to prevent illness as opposed to treating one.  Medicare Part D plans cover commercial vaccines if they are reasonably necessary.

Some vaccines covered by Part D

1. Shingles vaccines
2. Tdap (tetanus-diphtheria-whooping cough) vaccines
3. In cases that a PDP plan’s formulary does not list a vaccine, it must provide coverage if a physician prescribes it as a prevention measure.

Learn about the Medicare Part D drug cap

As of January 2023, patients with Medicare Part D plans or MAPD plans pay no out-of-pocket costs for adult vaccines.  This is part of the Inflation Reduction Act of 2022.  If the patient is charged a vaccine administration fee at the time of service, they can submit this amount to their Part D plan for full reimbursement.

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Part D late enrollment penalty appeal

Medicare beneficiaries who don’t sign up for Medicare Part D coverage during their initial enrollment period and go for a period of 63 or more continuous days without creditable prescription coverage may incur a late enrollment penalty.  If the beneficiary receives an LEP and they believe it is in error, they can initiate a Part D late enrollment penalty appeal.

Once a beneficiary enrolls in a Part D plan, the plan notifies them in writing if it is determined that the enrollee has incurred an LEP.  If plan administrators believe the enrollee has had a lapse in creditable prescription coverage for a continuous period of 63 days or more. The enrollee receives an LEP Reconsideration Notice and LEP Reconsideration Request Form with the written notification.

Learn more about enrollment in Part D

Either the enrollee or their representative can ask for a review, or reconsideration, of the LEP.  The LEP reconsideration request form provides enrollees a list of circumstances when they can request a review.

LEP Reconsideration Notice

The Part D LEP reconsideration notice gives enrollees an explanation of their right to request a reconsideration of their LEP.  Sponsors of Part D plans must complete the notice and send it to the enrollee with the letter notifying them of the imposition of a Late Enrollment Penalty.

To download a copy of the Sample late enrollment penalty reconsideration notice – click here.

Reconsideration Request Form

Part D plan enrollees should use the form, “Part D LEP Reconsideration Request Form C2C” to request an appeal of the LEP decision. The enrollee completes the form, signs it and then send it to One of the options below:

If you are sending via standard mail; C2C Innovative Solutions, Inc., Part D LEP Reconsiderations, P.O. Box 44165, Jacksonville, FL 32231-4165

Sending by courier or tracked mail; C2C Innovative Solutions ,Inc., Part D LEP Reconsiderations, 301 W. Bay St., Suite 600, Jacksonville, FL 32202

You can also send either by fax to; 833-946-1912 or upload the form to the website https://www.c2cinc.com//Appellant-Signup.  Once you are on the website, you will need to create an account and follow the prompts from there.
If you have a friend, family member or doctor send the request, that person must be your representative. They can complete the last form in the reconsideration request form.   The form is fillable online or you can print it out and fill it from there.

Click here to download the LEP Reconsideration Request Form

LEP appeal process

The LEP appeal process is conducted by an IRE (independent review entity) that has a contract with Medicare. The IRE notifies the enrollee of the final LEP decision within 90 days of receiving the request.  This includes the dismissal of the request.

Please note:  If you receive Extra Help, you do not have to pay a Late Enrollment Penalty.  Click here to learn more about Extra Help programs.

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Medicare Part D 2024

In this post, we will discuss some important information about Medicare Part D 2024.

Medicare Part D plans cover the cost of prescription drugs for Medicare enrollees.  Private insurance companies offer these plans to beneficiaries.   In order to remain complaint, all plan providers must follow CMS’ rules.

Prescription plan costs

There are a few costs associated with Medicare prescription plan coverage.  One of those costs include the monthly plan premium, this amount can range greatly depending on the plan and carrier.  Beneficiaries can opt to have the premium deducted from their monthly Social Security payment.  If the beneficiary has a greater than average income, they may be subject to an IRMAA, an adjusted premium amount based on income.  The premium may also be adjusted for those who have a lower-than-average income and qualify for Extra Help.

Other costs associated with Part D prescription are co-pays and coinsurance amounts paid at the pharmacy.  Many plans also include an annual deductible.  In 2024, the maximum annual deductible has increased from $505 in 2023 to $545 for 2024.

For those who neglect to sign up for a Medicare Part D plan on time, a late enrollment penalty is added to the monthly cost.  The penalty applies to anyone who goes without creditable Part D coverage for a period of 63 or more days.  CMS applies the penalty for as long as the beneficiary has Part D coverage.

Changes for Medicare Part D for 2024 

Because of the Inflation Reduction Act that was signed into law in 2022, there will be changes to the Medicare Part D program.   One important change has to do with the cost Medicare beneficiaries pay for prescription drugs.

 Click here to learn about prescription drug caps

Here are some of the changes in place for 2024:

In 2024, Medicare PDP members who reach the catastrophic phase ($8,000 in 2024) will not pay any additional out-of-pocket costs for the remainder of the year.  This means they are no longer subject to a 5% copay.

PDP plans are no longer able to raise their premiums over 6% per year starting in 2024.

Beneficiaries who use insulin will pay no more than $35 for a 1-month supply for covered insulin brands.  It is important to check your plan’s formulary to confirm which brands they include.  This pricing is in effect until the end of 2025.

Medicare covers many adult vaccines at no cost to Medicare beneficiaries.  this includes the Shingles vaccine as well as TDAP (tetanus vaccine), Covid, flu vaccine, Hepatitis A and many others.

More Medicare beneficiaries will qualify for Extra Help to pay for their health care needs in 2024. This is because beneficiaries with an income of up to 150% of the federal poverty level (up from 135% in 2023) may be qualified for the Part D Extra Help.  This program pays the Part D annual deductible, monthly premium and ensures beneficiaries pay a lower cost for generic and brand name drugs.

A few changes to prescription drug plans in 2025 and 2026

In 2025, one of the changes to the Part D program is a $2,000 out-of-pocket maximum in place for PDP beneficiaries.  CMS is also starting a prescription payment plan program.  The program is referred to as “smoothing” and begins Jan 1, 2025.  This program gives beneficiaries an opportunity the spread out the cost of prescription medications out over the year by using a payment plan.

Click here to learn more about the prescription payment program

In 2026 price negotiations will begin for expensive drugs that have no generic alternatives.

Learn the details of the price negotiation program

To view a comprehensive guide to all the ins and outs of Medicare for 2024, click this link and  download a copy of CMS Medicare and You handbook for 2024.    Information on Medicare Part D starts around page 79.

Watch a quick YouTube video on the drug cap proposed for 2025

Take a look at some of the other compliance updates CMS has in place or has proposed for agents :

Watch a quick YouTube video on the CMS proposed rule CMS 4205-P an how this could effect our business

Find out more about the 2024 CMS call recording requirements

Make sure you are up-to-date with the SOA rules – click here and learn more

Take a look at our video on TPMO rules for 2024

If you are unsure of the differences between an educational event and a sales event, click here.  You may also want to read our blog on “Things you can’t say when selling Medicare“.

If you already have a contract with Crowe and want to add a carrier, click here

Agents who want to join the team at Crowe, click here for online contracting

Please note: agents who offer Medicare Part D plans need to complete annual carrier certifications as well as AHIP before they can offer the plans.  AHIP is an annual certification that CMS requires.  It includes marketing and compliance guidelines as well as FWA laws.

If you don’t follow the Medicare marketing rules, you risk losing commissions, termination of your contracts, losing your license and receiving fines.

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Wellcare prescription plans

Because the ability to access affordable prescription medications is crucial to maintaining good health, beneficiaries must be aware of all their options.  In order to help individuals make an informed decision, we will discuss some benefits of the WellCare prescription drug plans.

Important; CMS has guidelines in place to regulate the types of medications that prescription drug plan providers must cover.  This includes a minimum standard of benefits for providers to follow. The formulary for each plan Each plan meets the requirements as required by law. Because each plan differs, the cost and drugs included in the formulary can vary.

Find out about the Medicare drug price negotiations

Although Wellcare offers three different plan choices, it is important to review each plan formulary and make sure it provides coverage to fit the prescription needs for anyone considering enrollment.

The three Wellcare PDP plans for 2024

Some features of the Wellcare prescription plans

Wellcare has no or low premium plans available to provide coverage for individuals who qualify for Extra Help.  These plans are available in all states and offer low or no copays when enrollees purchase prescriptions from preferred pharmacies.

Some Wellcare plans include no deductible, so plans cover prescriptions on day one.

Wellcare has a nationwide network of preferred pharmacies that includes thousands of national, regional and local pharmacy chains. It also includes grocers and independent pharmacies as well.  These relationships help plan members save money on prescription drugs.

Use this link to the Wellcare preferred pharmacy tool and find a local in-network pharmacy.

Find a preferred pharmacy tool to find a local pharmacy.

The member service representatives are available either online at wellcare.com/PDP or by phone at 866-822-1339 (TTY – 711) during the hours of 8am – 8pm EST Monday – Friday. They can provide answers to members coverage or medication questions.

If you want to view the plan formulary (complete list of drugs each plan covers), visit Wellcare’s website or contact their member services department.

Aetna SilverScript

For Medicare beneficiaries who are on Original Medicare or Original Medicare and a Medicare Supplement plan, it is a good idea to add a Medicare prescription drug plan to cover your prescriptions. One prescription drug plan that provides coverage to many beneficiaries is the Aetna SilverScript Plan.  In this post, we will go over some of the benefits these plans provide.

Aetna SilverScript Overview

Aetna SilverScript is a Medicare prescription drug plan provider.  It is part of the Aetna family of medical insurance plans. These plans are designed to work with Original Medicare or Medicare supplement plans and cannot be sold to anyone who is currently enrolled in a Medicare Advantage plan and wants to remain on that plan.

Eligibility for prescription plan enrollment

In order for a beneficiary to eligible for enrollment in any PDP plan, they must be enrolled in either Medicare Part A or both Medicare Part A & Part B.  Beneficiaries must also live in the service area of the plan they want to enroll in.

There are specific times you must use to enroll in a Medicare prescription drug plan (Part D).

1. During your initial enrollment period (IEP).
2. Enroll during the Annual Election period (AEP).
3. If you have a Medicare Advantage plan, you can enroll during the Medicare Advantage Open Enrollment Period (MAOEP).
4. When you qualify for a special election period (SEP).

Learn more about Medicare’s enrollment periods

Aetna SilverScript plans

In 2024, Aetna is offering 3 different plan choices:

1. First, the SilverScript Smart Saver plan – This plan has an average monthly premium of $11.19, Please note, this cost is an average.  Actual cost depends on the service area. This plan offers a $0 copay for a 30-day supply of Tier 1 drugs.   There are almost 600 drugs that fall into Tier 1 and Tier 2 on this plan, drugs on tier 2 have a copay amount of $5.  The SilverScript Smart Saver plan also provides members a low deductible of $280 for Tier 2 through Tier 5 drugs.
2. Second, the SilverScript Choice plan – Members of this plan pay an average monthly premium of $46.59.  Please note, this cost is an average and the actual cost depends on the service area.  There is a $545 deductible applied to all tiers of this plan.  The copay amount for Tier 1 drugs is $2 while the Tier 2 copay amount is $7.  Beneficiaries who qualify for Extra Help do not have to pay a plan premium.
3. Third, the SilverScript Plus plan – The premium for this plan averages $103.51 although the actual amount varies depending on the service area.  This is a top-notch plan that offers members a $0 deductible for both Tier 1 and Tier 2 drugs.  On this plan, there is a $0 copay for many prescription vitamins, minerals and some other types of drugs. members also receive additional gap coverage.

Watch a video on Drug plan changes for 2024

Features of Aetna SilverScript PDP plans

Variety of Plans

Aetna offers a wide range of prescription drug coverage options.  This allows beneficiaries to choose a plan that aligns with their personal needs and budget.  Each plan covers different medications at varying costs.

Extensive Network of Pharmacies

All Aetna SilverScript plans offer an extensive network of pharmacies.  This gives beneficiaries the flexibility and convenience to choose where they fill their prescriptions.

Mail-Order Options

The Aetna SilverScript plans provide the option for mail-order prescriptions, allowing beneficiaries to receive a 90-day supply of their medications conveniently delivered to their door.

Members of Aetna SilverScript PDP plans can visit AetnaMedicare.com to access and print plan materials, pay their plan premiums, check coverage of their drugs or locate a local, preferred pharmacy.

Aetna also provides members a secure site, Caremark.com, to find prescription prices, see possible prescription savings options, sign up for mail delivery, check order status and more.

Click here to learn why you should use a Medicare agent

To see if these plans are right for you, check with a licensed Medicare agent who can ensure your coverage needs are properly met by either these plans or another one.

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Why use a Medicare agent

If anyone asks why use a Medicare agent, we can provide you with some good reasons anyone should consider using a Medicare agent.

Because Medicare agents complete hours of training on both compliance regulations and the Medicare products available in their area, they are well versed on the plans available and provide valuable information to clients. They can provide clients and potential clients comparisons of several plan options and help find the Medcare plan that best fits their needs.

To learn the difference between Medicare Advantage and Medicare Supplements, click here

Compare plan choices

Because health insurance coverage is such an important decision, it is important for clients to understand all their choices. Choosing the wrong plan can be a very costly mistake.  For this as well as many other reasons, the help of a licensed Medicare agent is essential. A Medicare agent can go over the client’s list of wants/needs for coverage and find plan options that are right for them. Agents help clients weigh the benefit of each plan. Medicare plan benefits, rules, and exceptions may be overwhelming to sort out without a trained professional.

To find out about our quoting tools, Connecture and Sunfire, click here

Consider the client’s current coverage

It is important to consider the client’s current Medicare coverage and find out what about the plan works or does not work for them.  With this information in mind, it is easier to find help them decide whether they should stay in their current plan or if there are better options available to them.

Agents do not charge for their service

As a Medicare agent, you cannot take money from the client for the advice you provide.  This means clients receive expert advice at no cost.  This service is provided for free.  That is one deal you cannot beat!

Medicare agents receive payment through a couple different ways depending on the type of agent they are.  Agents who are employed by and insurance company receive payment based on their agreement with their employer.  Many other agents who are not captive with a carrier, receive payments through the commissions they earn.  They may receive this payment directly from the carrier or if they are LOA, they receive payment from their up-line.  Either way, the amount they make is based on their total number of sales made.

Please note: commission amounts vary based on the plan type and carrier as well as the level each individual agent is contracted at.

Find out about commission levels for 2024

How clients choose a Medicare agent

Here are some things clients may consider when they choose a Medicare agent.

1.  The first way clients choose an agent is usually word of mouth.  If you have done a great job helping their friends, relatives or co-workers, believe me they will hear about it.  People love to tell their friends about an agent who really did a good job for them.  That is why all your clients need to know that you are there to answer any questions or concerns they have.
2. Clients feel better knowing they are working with an experienced agent someone who understands the plan benefits and how they work.  Be sure you are up to date on all the plans in the areas you sell in as well as what the rules for enrollment are.
3. Offer many different carries and plan types for each area you sell in.  Clients want to work with an agent who has access to all the best plans in their area.  Each client is an individual and one plan type may not be the best choice for every client. Do not offer only Medicare Advantage plans as some clients are better off with a Supplement and PDP plan.

Click here for a scope of appointment

A knowledgeable and caring Medicare agent is a very valuable resource for the community. If you make sure you are well informed and truly enjoy helping those who need advice on Medicare coverage, you can become a successful agent with the right amount of time, effort & training.

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Medicare prescription payment plan

The Medicare prescription payment plan is also referred to as “smoothing“. This is a way to help Medicare beneficiaries pay for the high cost of prescription medications.  The Medicare prescription payment plan is one small part of the inflation reduction act of 2022.

Watch a quick YouTube video on potential changes to commissions in 2025

When will the program start

In 2025, Medicare Part D (PDP) plan enrollees have a chance to opt for a prescription payment program.  The plan will help beneficiaries pay out-of-pocket costs for prescriptions.  Everyone in a PDP plan has a chance to enroll in the payment program, it is not based on income.  Enrollees have the option to enroll before the plan year starts or during any month of the year.   Please note, the payment plan does not include plan premium payments.

Here are some of the details

Participation in the Medicare prescription payment plan is optional.  PDP plan enrollees must choose to be part of the program.  Once an enrollee joins the program, and has out-of-pocket prescription costs, they receive a monthly bill to cover those costs.  Any out-of-pocket costs for prescriptions are included even during the deductible phase of PDP coverage.  There is no minimum out-of-pocket amount required before anyone can join.  Participants receive a monthly bill as long as they remain part of the program.

How is the monthly payment amount decided

There will be an annual cap of $2,000 on out-of-pocket costs in 2025.  The amount each beneficiary pays for their monthly plan depends on a few different factors.  It is not as easy as dividing $2,000 over the course of 12 months.

Learn more about the Part D drug cap

1. The Medicare prescription payment plan will deduct the out-of-pocket amount beneficiaries have already paid before enrollment in the program.
2. Any remaining costs are then divided by the number of months left in the year.

CMS will create a payment calculator so Part D beneficiaries can decide if enrolling in the payment plan is a good idea or not.

CMS is still working out the details of this program

We do not know exactly how the prescription payment program will work yet because the details have not been finalized by CMS yet.  We will post additional details as they are available to the public.

Please note:  This program is set to start in 2025, the same year the annual drug cap will be set at $2,000.  In other words, no Part D enrollee will pay more than $2,000 out-of-pocket for their prescriptions.

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