I have severe rheumatoid arthritis and my biologic medication costs $6,000 per month. How will the 2025 Medicare Part D changes affect someone in my situation?

Question

Steven Bleicher · Accepted Answer

Greatly!! The passage of the Inflation Reduction Act last year means that the most you will spend on known Rx’s (not ones of an experimental nature) is going to be $2,000.00 which Medicare will keep track of. Bear in mind that the $6K is preposterous! This could also mean that as long as you know that a “bio similar” drug is not recommended by your doctor as a substitute, in the very 1st month, you have already surpassed the maximum out of pocket! This is going to be a boon to your expenses this year.

Answered by Steven Bleicher on April 15, 2025

Broker Licensed in AZ

Answered by Steven Bleicher Medicare Insurance Agent

Nikki Rowland · Answer

Your total annual out-of-pocket cost for Part D-covered medications will be capped at $2,000.

Once you’ve paid that amount, you won’t pay anything more for covered prescriptions for the rest of the year.

You would need to make sure your medication is a Medicare covered medication in order for the Max $2000 to apply.

Michael Andrews · Answer

If you have a prescription drug plan either through a Medicare Advantage plan or a stand alone part D plan, the most you will be responsible for is $2,000 out of pocket for the year as long as your prescriptions are in the formulary of the plan.

Answered by Michael Andrews on April 15, 2025

Broker Licensed in CT

Answered by Michael Andrews Medicare Insurance Agent

Randall Taylor · Answer

By federal law, you will pay no more than $2,000 for prescriptions drugs in 2025. This provision was included in the 'Inflation Reduction Act' passed by the US Congress. This provision is expected to continue each year.

Answered by Randall Taylor on May 6, 2025

Broker Licensed in TX, MI & WI

Answered by Randall Taylor Medicare Insurance Agent

Lance Stanley · Answer

2025 Medicare prescription drug plan are now capped at $2000.00 annually. So, after you reach that amount of out of pocket cost you will not have any out of pocket cost the rest of the year.

Scott Sims · Answer

Since we now have a $2,000 cap on medications for Part D Medicare per year, this person should only be responsible for $2,000 of out of pocket costs. Insurance carrier will pick up the rest of the cost for the year for Part D drugs.

Answered by Scott Sims on April 9, 2025

Broker Licensed in OR, AZ, CA & 15 other states

Answered by Scott Sims Medicare Insurance Agent

Jillian Bellinger-Laing · Answer

Medicare has a $2000 out of pocket maximum this year for drug costs (this includes the $590 deductible if your plan has one). Once you have paid $2000, then you will fall under catastrophic coverage and pay $0 for the rest of the year.

Answered by Jillian Bellinger-Laing on May 12, 2025

Broker Licensed in PA, DE, FL & 6 other states

Answered by Jillian Bellinger-Laing Medicare Insurance Agent

Sherry Rose · Answer

The 2025 Medicare Part D changes, will significantly benefit someone like you with rheumatoid arthritis. Once you reach the $2,000 limit, you won't have to pay any more out-of-pocket for covered Part D drugs for the rest of the year.

Answered by Sherry Rose on June 2, 2025

Broker Licensed in Ga, AL, AR & 5 other states

Answered by Sherry Rose Medicare Insurance Agent

Diana Garner · Answer

In previous years, Medicare Part D had a few different phases, such as:
     1) Deductible - beneficiaries pay 100% of the cost until the deductible is met.
     2) Initial Coverage - plan starts to pay a percentage of the medication costs.
     3) Coverage Gap (Donut Hole) - Beneficiary pays a higher percentage of medication costs.
     4) Catastrophic Coverage - once the out-of-pocket for medication reaches the specified amount, the plan and the government pay more. In contrast, the beneficiary pays a small copay/coinsurance.

With the Medicare Part D changes that have taken place for 2025, beneficiaries who are prescribed higher-cost medications, such as your biologic, will see a significant decrease in the cost. You will only be out-of-pocket $2,000 for the entire year.

Cindy Clonts · Answer

This answer is provided in a video format. Watch the agent's video response here: https://medicareagentshub.com/questions/biologic-medication-costs-2025-part-d-changes#cindy-clonts

Michael Crocker · Answer

As long as you are on a Part D plan that includes your medication in its formulary, your out-of-pocket costs will be capped at $2000. Please keep in mind that your plan premium isn't included in this $2000 cap, so your total out-of-pocket could be more, depending on your premium.

Answered by Michael Crocker on June 3, 2025

Broker Licensed in SC

Answered by Michael Crocker Medicare Insurance Agent

Jaye Maxx Alexander II · Answer

Biologic treatments for rheumatoid arthritis (RA) are medications that target specific parts of the immune system to reduce inflammation and joint damage. They are often used when conventional disease-modifying antirheumatic drugs (DMARDs) haven't been effective. Biologics can be administered via injection or infusion. They fall under your Part B coverage, not your Part D coverage.

Answered by Jaye Maxx Alexander II on April 29, 2025

Broker Licensed in NC, AK, AL & 47 other states

Answered by Jaye Maxx Alexander II Medicare Insurance Agent

Wild Bill Anderson · Answer

We will be sure your drug is on the plans list.  As long as it is you can spend no more than $2000 a year for covered drugs.

Natalee Nimmo · Answer

The part D changes for 2025 have impacted a lot of things. First of all the prescription drug plans have changed their formulary so you may find that your particular medication is not being covered. If you do find a plan that covers it your monthly premiums for that planmay be very high. If you find a plan that does cover it then the most you’re going to be out for your medication‘s for the years $2000. If you can’t find one that covers it then there are programs out there to help people in that situation, I would recommend contacting an agent or broker to help you in that regard.

Answered by Natalee Nimmo on June 9, 2025

Broker Licensed in SC, FL, GA & KY, MO, NC & TX

Answered by Natalee Nimmo Medicare Insurance Agent

Sophia Davis · Answer

If your biologic is administered at a facility, this is typically billed under Medicare Part B instead of D, therefore the Inflation Reduction Act changes will have no bearing. What will help is being on a plan with a lower Max-out-of-Pocket cost.

Answered by Sophia Davis on April 21, 2025

Broker Licensed in OH & PA

Answered by Sophia Davis Medicare Insurance Agent

Ryan Ross · Answer

Starting in 2025, Medicare Part D will have a $2,000 out-of-pocket cap for prescription drugs. That means no matter how expensive your medications are, like your $6,000 a month biologic medication, you won’t pay more than $2,000 total for the whole year on covered prescriptions.

This change will offer huge relief for people like you with high-cost medications. It helps make treatments more affordable and predictable, so you can focus on feeling better instead of stressing about the cost. Let me know if you’d like help reviewing your current plan or switching to one that works best with these new changes!

Christopher Stewart · Answer

Medicare removed the coverage gap thanks to the Inflation Reduction Act. This is a major benefit for beneficiaries as they will most likely be saving thousands on their meds, especially if they are used to spending $6,000 per month as the new prescription max is $2,000 annually. However, in order for the new $2,000 prescription max to work all of your meds must be covered by your plan's formulary. If it is not, then we can look at manufacturer's discounts and other avenues to try to find ways to save on the medications.

Answered by Christopher Stewart on May 12, 2025

Broker Licensed in FL, AL, AZ, CO & KS

Answered by Christopher Stewart Medicare Insurance Agent

Leisha Stevens · Answer

The 2025 Medicare Part D changes, particularly the new $2,000 out-of-pocket cap, will significantly benefit individuals like you who have high prescription drug costs, such as those for rheumatoid arthritis (RA) biologics. This cap means you won't pay more than $2,000 in out-of-pocket costs for your covered drugs in 2025, regardless of the total cost.

Answered by Leisha Stevens on May 19, 2025

Broker Licensed in OH, CA, FL & NC

Answered by Leisha Stevens Medicare Insurance Agent

Gene Page · Answer

Good News! There is a $2000 annual limit you will be required to pay on part D drugs. This has been getting better each year.

Carl-Daniel Cole · Answer

Starting in 2025, Medicare Part D will include a $2,000 annual out-of-pocket cap on prescription drugs. For someone taking high-cost medications like biologics, this change can significantly reduce your yearly expenses. It’s designed to offer better financial protection for beneficiaries with serious conditions.

Answered by Carl-Daniel Cole on May 20, 2025

Broker Licensed in MO, AL, AR & 23 other states

Answered by Carl-Daniel Cole Medicare Insurance Agent

Lenora Sikkenga · Answer

Beginning in 2025, the annual out-of-pocket spending cap for Part D enrollment will $2000. This includes deductibles and copays and co insurance but does not include premiums. So after the two thousand dollars has been met there is no other out of pocket expense

Answered by Lenora Sikkenga on April 14, 2025

Broker Licensed in NV

Answered by Lenora Sikkenga Medicare Insurance Agent

Jennifer Osborne · Answer

As long as your prescription plan covers the medication, your annual maximum prescription cost will be $2,000. But, if your plan does not cover the formulary, it does not apply toward that maximum, so best to review your current plan for formulary coverage.

Answered by Jennifer Osborne on April 9, 2025

Broker Licensed in KY, FL, IL, IN, NE & OH

Answered by Jennifer Osborne Medicare Insurance Agent

I have severe rheumatoid arthritis and my biologic medication costs $6,000 per month. How will the 2025 Medicare Part D changes affect someone in my situation?

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I have severe rheumatoid arthritis and my biologic medication costs $6,000 per month. How will the 2025 Medicare Part D changes affect someone in my situation?

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