Consumers in and across the country face too many challenges when it comes to accessing the care they need. Find #HealthCareReform stories here.
- What does this mean for Medicare Part D enrollees?
- Medicare Part D recipients will never pay more than $2,000 in total out-of-pocket costs in 2025 for prescription drugs, even if they don’t opt into the Medicare Prescription Payment Plan.
- For those who opt into the Medicare Prescription Payment Plan they will pay nothing for their prescriptions at the pharmacy. Out-of-pocket costs for Part D medications will be divided into monthly payments based on a standard formula, which will adjust depending on the patient’s cost sharing to date and the remaining months in the plan year. In addition to any monthly premium costs, patients will be billed each month by their Part D or Medicare Advantage plan for the drug costs they owe.
- Who will benefit?
- All Medicare Part D beneficiaries will benefit from the $2,000 cap on total out-of-pocket Part D prescription drug costs.
- The Medicare Prescription Payment Plan is open to all beneficiaries who opt in. The Plan will most help those who expect to have high out-of-pocket medication costs, especially in the early months of the year.
- How do I sign up?
- You can opt in through your Part D or Medicare Advantage plan directly. It is best to opt in during open enrollment as it may take time to process the election if a patient opts in during the plan year.
- Visit Medicare.gov/prescription-payment-plan or call 1-800-MEDICARE to learn more.
- Forcing consumers to delay important tests and treatments or making them pay out-of-pocket for expensive procedures and medications when they have health insurance is outrageous. Forcing patients to wait days, weeks and even months for the procedures and medicines they need can have life-threatening consequences.
- A recent review of Medicare Advantage prior authorization requests revealed that just one of every ten prior authorization requests that were denied in 2022 were appealed. Importantly though, more than 80% of the denials that were appealed resulted in the insurer partially or fully overturning the denial.
- How can I appeal a prior authorization denial?
- Learn more about appealing an ACA health plan decision at Healthcare.gov.
- If you disagree with prior authorization denial by a Medicare Advantage plan, original Medicare or another Medicare plan, visit Medicare.gov
- The bottom line: The prior authorization system creates consequences for patients and the delays incurred during the appeal process may have negative health repercussions. Patients should use the tools available to appeal care denials.
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