This one thing you must know for 2025 Part D Medicare

Why is my prescription so expensive THIS MONTH?

Have you ever paid the same amount for the same prescription every month, and then suddenly, the price is triple? It is the same prescription, exact dosage, from the same doctor.

Likely, you fall into the Donut Hole (Coverage Gap) of Medicare Part D.

The Medicare Part D drug plan has four stages, and the donut hole is the stage that causes many people financial hardship.

Stage 1: Annual Deductible

For 2024, if your drug plan has a deductible, the maximum annual deductible is $545. After you pay for that, your Part D drug plan starts to pay for you.

Stage 2: Initial Coverage

Depending on your copays or coinsurance, you the member, and the plan pay up to $5,030

Stage 3: Coverage Gap the Donut Hole.

You pay 25%, the plan pays 5%, and the Pharmaceutical company pays 70%. You will exit the donut hole once all the parties pay up to $8,000.

Stage 4: Catastrophic Coverage

At this phase, you don’t need to pay for your prescription.

Scenario 1:

Tom is 66 years old and he takes Eliquis, a tier-three medication. His drug plan doesn’t have a deductible. At the beginning of the year, he usually pays $47 per 30-day supply. This month, he paid $141; he was shocked. He has fallen into the donut hole. To get out of it, Tom, the plan, and the pharmaceutical company have to pay up to $8,000 in total.

Great News in 2025

The donut hole will be eliminated in 2025 thanks to the Inflation Reduction Act.

The maximum true out-of-pocket (TrOOP) is capped at $2,000. This means you, the plan, and the drug manufacturers’ company don’t pay more than $2,000.

2025 Part D Benefit Redesign.

Stage 1: The Annual Deductible

The annual deductible for 2025 is a maximum of $525.

Stage 2: Initial Coverage

You paid 25%, the plan paid 65%, and the Drug Manufactures pay 10%

This phase ends when the $2,000 True out-of-pocket meet.

Stage 3: Catastrophic Coverage

You paid $0.

Let’s go back to our example.

Eliquis without insurance usually cost $561.

Tom is still paying for a $47 co-pay for Eliquis. The plan and the drug manufacturers are paying the remaining, $514.

In Month #1, Tom, the drug plan, and the drug manufacturers paid $561.

In Month #2 same thing, Tom, the drug plan, and the drug manufacturers paid $561.

By the fourth or fifth month, Tom will be paying $0 for his Eliquis because his TrOOP of $2,000 has been met.

For more information regarding Medicare information please contact:

K’s Tax Service and Health Insurance

(702)325-4276 Address: 1717 S. Decatur Blvd G7 and G8, Las Vegas NV 89102