Answers provided by Kelsey Hoelscher, Breitenfeldt Group licensed agent
What is the cap for Medicare Part D prescription drug costs?
Starting in 2025, Medicare Part D enrollees will have a $2,000 annual cap on out-of-pocket prescription drug costs. Enrollees will pay their deductible (if applicable) on covered prescriptions, then their cost-share until the $2,000 cap is met.
How does this cap differ from the previous Medicare Part D
structure?
In the past, Part D enrollees had to pay a percentage of drug costs even after reaching the catastrophic coverage phase with no limit on spending. With this new cap, once out-of-pocket spending reaches $2,000, enrollees will no longer have to pay for covered prescriptions for the remainder of the year.
Does this cap apply to all Medicare Part D plans?
Yes, the $2,000 cap applies to all standard Medicare Part D prescription drug plans and Medicare Advantage plans that include drug coverage.
What counts toward the $2,000 cap?
The cap includes money spent by the insured on deductibles, copays, and coinsurance for prescriptions that are covered by the Part D plan they are enrolled in.
What does not count towards the $2,000 cap?
1. Monthly Part D premiums – You must continue paying your plan’s monthly premium even after reaching the cap.
2. Over-the-counter (OTC) medications – Non-prescription drugs are not included in the cap.
3. Drugs not covered by your Part D plan – If a medication is not on your plan’s formulary (list of covered drugs), its cost does not count toward the cap.
4. Drug manufacturer discounts on brand-name drugs – While discounts help reduce costs, the actual discounted amount may not count toward your spending cap.
Can this cap change over time?
Yes, the $2,000 cap may be adjusted in future years based on Medicare policy changes and inflation.
Find out more
If you have more questions about Medicare, Breitenfeldt Group is here to answer them. We are an independent health insurance brokerage who has been serving the area for almost 30 years. There are never fees for our services and we offer year-round support with your health insurance. Simply give us a call at 877-732-9800 or email us at info@bghealthplans.com to connect with one of our licensed agents.
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