The Comprehensive Guide to Access- Prepping for Medicare Changes in 2025 By Angie Lee

Jan 2, 275760

Comprehensive Guide for Biologic/Access Coordinators: Preparing for Medicare Changes in 2025

By Angie Lee, CMA, CDT

As biologic/access coordinators and field reimbursement managers, it’s essential to stay informed about the changes Medicare patients will face in 2025. This understanding is critical for guiding patients through accessing life-changing therapies, especially high-cost medications. While the Inflation Reduction Act introduces a $2,000 out-of-pocket cap for Medicare Part D medications, patient costs will still vary depending on income, plan type, and other factors. This guide explores the upcoming changes and provides actionable strategies to support your patients effectively.


Understanding Medicare Cost Caps

1. Part D Prescription Drug Cap

Starting January 1, 2025, Medicare Part D plans will include a $2,000 annual out-of-pocket cap for prescription drugs. Here are the key points:

  • The cap applies to drugs listed on the plan’s formulary (covered drugs). Exceptions may be made for non-formulary drugs through an approval process.

  • Costs for premiums, Medicare Part B medications, and non-covered drugs are excluded from this cap.

  • This benefit is automatic—patients do not need to enroll separately.

  • The cap will adjust annually based on inflation.

2. Out-of-Pocket Maximum for Medicare Advantage Plans

Medicare Advantage plans have annual limits on total costs for Medicare-covered services. In 2025:

  • The maximum for in-network services is $9,350.

  • For combined in-network and out-of-network services, the limit is $14,000.

  • Patients will continue paying copayments or coinsurance until these limits are reached.

Note: Medicare Advantage plans may result in higher costs for biologics and specialty medications. Carefully evaluate these plans with your patients.


What is IRMAA?

The Income-related Monthly Adjustment Amount (IRMAA) is an additional charge applied to Medicare Part B and Part D premiums for higher-income beneficiaries. For 2025, the thresholds are:

  • Single Filers: Income above $106,000.

  • Married Filing Jointly: Income above $212,000.

The adjustments range from:

  • Part B: $74 to $443.90 per month.

  • Part D: $13.70 to $85.80 per month.

Coordinators should help patients understand if IRMAA applies to them and what additional costs they might expect.


Part A and Part B Costs for 2025

Medicare Part A and Part B costs will also see increases. Highlights include:

  • Part A Deductible: $1,676 per benefit period (up from $1,632).

  • Part B Deductible: $257 (up from $240).

  • Part A Hospital Copayments: Costs for extended stays and skilled nursing facility care will rise.

  • Part A Premiums: $285 or $518 monthly, depending on the patient’s coverage quarters.


The Importance of Understanding Medicare Part D Formularies

A plan’s formulary determines which drugs are covered, any restrictions, and how costs are tiered. For biologic/access coordinators, familiarity with formularies is crucial for:

  • Ensuring patients have access to their prescribed medications.

  • Preventing disruptions in care due to non-coverage or restrictions.

  • Helping patients manage costs effectively.


Medicare Advantage Open Enrollment Period

From January 1 to March 31, Medicare beneficiaries can:

  • Switch Medicare Advantage plans.

  • Disenroll from Medicare Advantage and return to Original Medicare with the option to enroll in a Part D plan.

This period is a critical time to ensure patients are in plans that meet both their medical and financial needs.


Actionable Strategies to Support Patients

Biologic/access coordinators play a vital role in helping patients navigate the complexities of Medicare changes. Here are strategies to implement:

1. Review Coverage Options

  • Guide patients in selecting plans that align with their medical and financial needs.

  • Encourage patients to review plan formularies and associated costs during the annual enrollment period.

2. Educate Patients

  • Explain cost caps, formulary details, and additional fees like IRMAA.

  • Provide clear information to empower patients to make informed decisions about their coverage.

3. Utilize Assistance Programs

  • Identify and help patients apply for assistance programs to offset medication expenses.

  • Be aware that some patients may not qualify for these programs and explore alternative support options.

4. Coordinate Care

  • Collaborate with healthcare providers to ensure patients have access to medications without delays.

  • Minimize disruptions caused by prior authorizations or coverage issues by proactively addressing them.


Conclusion

Medicare changes in 2025, including the $2,000 out-of-pocket cap for Part D medications, are designed to improve affordability for patients. However, costs can still vary, and biologic/access coordinators must remain vigilant in navigating these complexities.

By staying informed and implementing these strategies, coordinators can support patients in accessing necessary therapies while managing their financial responsibilities. With your expertise, patients can benefit from uninterrupted care and improved health outcomes, making a life-changing difference for those you serve.


Preparedness is key. By understanding these changes, you can provide the guidance and support your patients need to thrive in 2025 and beyond.

Copyright 2024 © BC Educators LLC

Copyright 2024 © BC Educators LLC

Copyright 2024 © BC Educators LLC