MEDICARE Part D (Prescription DRug Coverage) - FAqs

Lower Catastrophic limit: If you're taking high-tier medications and you reach the catastrophic coverage phase, you will not have a copayment or coinsurance.  Starting in 2025, the yearly Part D out-of-pocket costs will be capped at $2,000. You'll also have the option to pay out-of-pocket costs in monthly amounts over the plan year as opposed to when they happen.  

Capped Part D Insulin Costs: Your Medicare drug plan is not allowed to charge more than $35 for one-month supply of each Part D-covered insulin.  Deductibles do not apply.  If you get a 3-month supply, your costs are capped at $105 ($35 for each month). 

Drug Price Negotiations:  Although new pricing will not be effective until 2026, Medicare has negotiated and finalized drug pricing directly with manufacturers for the following high-tier medications.  Prices for the first 10 drugs will be effective Jan 1, 2026.  More info available here. 

The first 10 drugs on the list include:

• Eliquis
• Jardiance
• Xarelto
• Januvia
• Farxiga
• Entresto
• Enbrel
• Imbruvica
• Stelara
• Fiasp; Fiasp FlexTouch; Fiask PenFill; NovoLog; Novolog FlexPen; Novolog PenFill 

Your Part D costs will vary by the plan you choose.  Plans may have fixed monthly premiums and you may be responsible for deductibles, copayments, and/or coinsurance when you fill prescriptions at a pharmacy.    

This is an amount you may pay in addition to  your prescription drug (Part D) premium if your income is above a certain level.  Click here to view income thresholds and income-related monthly adjustment amounts.  

Many plans have preferred pricing at select pharmacies so it would be wise to make note of the "preferred" pharmacies and use them to minimize your out-of-pocket costs.  You can find a list of "preferred" pharmacies through your plan benefit materials or online member portal.    

Annual drug plan deductibles for most plans will be $590 in 2025.  There may be plans available with a lower deductible or a zero deductible in your area - but a lower deductible does not guarantee you will have lower out-of-pocket costs on your medications. 

You can switch plans and change your drug coverage during the Annual Election Period (AEP), which lasts from October 15 to December 7 each year.  If you qualify for a Special Enrollment Period (SEP) because of a qualifying situation, you can make a change outside of the AEP.     

Your drug plan decision should be based on your medications and the pharmacy you wish to use.  Medicare offers a user-friendly "Medicare Plan Finder" tool that can help you compare and estimate out-of-pocket costs for drug plans available in your area.  

If you are a current client of Waxman Insurance and would like assistance, we may be able to provide you with a complimentary review of your drug plan during the Annual Election Period (AEP).