Changes to Medicare prescription drug coverage in 2025 | FOX6 Milwaukee

Changes to Medicare prescription drug coverage in 2025

More than one million people in Wisconsin have prescription drug coverage through Medicare Part D or the Medicare Advantage plan, according to KFF. As of Jan. 1, 2025, those people are now eligible for a spending cap on their plan's approved prescriptions.

Seniors impacted

What we know:

At the Wilson Park Senior Center in Milwaukee, there are ways to stay fit and agile. In an advanced tap-dance class, Contact 6 met women ages 67 to 93. 

Tap-dancing is one way to stay healthy, but many seniors also rely on prescription drugs. Every woman in the tap dance class told Contact 6 they're on Medicare.

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Sitting outside the class was Sharon Nachtwey, a diabetic on Medicare. Nachtwey says she struggles to afford her monthly medications.

Sharon Nachtwey

"It is expensive," said Nachtwey. "I don't have expenses for other things, like helping out with my grandchildren."

Pharmacists are aware

What they're saying:

It's something Marwa Bakr, owner of Infinity Pharmacy in Milwaukee, says she sees firsthand.

"(Customers) stop filling their prescriptions," said Bakr.

Bakr says many common medications for diabetes, migraines, blood pressure, asthma and other chronic conditions can be expensive.

"I have one patient who decided to take (her prescription) every other month, instead of every month," said Bakr. "She said, "I can't afford filling it every month."

Inflation Reduction Act

The backstory:

The Inflation Reduction Act of 2022 included significant changes to Medicare's prescription drug coverage. Among the biggest changes in 2025 is a $2,000 spending cap on out-of-pocket costs.

Sadie Tuescher, a licensed health insurance agent, said she's assisted patients paying more than $2,000 in a single month.

"It will make a really big difference for people with certain chronic conditions. People who take prescription medications that are more expensive," Tuescher said. "Anyone in a Medicare program, regardless of income or resources, has the $2,000 cap."

The $2,000 cap does not include premiums associated with the Medicare drug plan. It applies only to prescriptions covered by the beneficiary's drug plan.

Changes in 2025 also eliminate the so-called "donut hole," a coverage gap in-between drug costs that went beyond the initial coverage limit, but didn't yet qualify for the next phase of catastrophic coverage.

Medigap Helpline Program

Dig deeper:

"They're not going to see that fluxuation through the coverage gap phase that they've seen in the past," said Nick Lutes, supervisor of the Medigap Helpline Program.

Lutes says beneficiaries must opt in to take advantage of the second big change in 2025: the Medicare Prescription Payment Plan. Lutes says the plan allows them to spread out prescription drug costs throughout the year, rather than paying more in the beginning.

Nick Lutes

Lutes calls the changes to Medicare prescription coverage in 2025 a "revamp."

"It's an entire restructuring of how Medicare prescription drug coverage is structured for beneficiaries," said Lutes.

Senior concerns

Local perspective:

At the Wilson Senior Center, Nachtwey expressed concern about the future of Medicare's prescription drug coverage.

"With the new government system, everything to me is unknown," said Nachtwey.

One of President Trump's first executive orders reversed a Biden-era initiative aimed at lowering prescription drug prices for people on Medicare. Lutes says "at this point, the recent executive actions haven’t had any effect on the Medicare Prescription Payment Plan or $2,000 out-of-pocket cap, as far as I'm aware."

At the Kelly Senior Center in Cudahy, Contact 6 met Douglas Tadeyeske. Tadeyeske is a diabetic with a history of stroke and seizure. He says he'll easily meet the $2,000 prescription drug cap.

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"This will impact me majorly," said Tadeyeske.

Douglas Tadeyeske

Tadeyeske showed Contact 6 the cards he carries in his wallet that list his emergency contacts and prescriptions. Those medications keep him healthy enough to volunteer at the center, signing in its visitors for lunch.

"Lowering this max is going to help a lot of people," said Tadeyeske.

There are critics of the changes who say the spending cap should be lower or more medications should be covered. Others say the changes will drive up Medicare premiums. If you have questions about Medicare prescription drug coverage, call the Medigap Helpline at 1-800-242-1060

What now?

What you can do:

To enroll in a Medicare prescription payment plan, call the number on the back of your membership card.

Looking ahead to 2026, another major change scheduled for Medicare is the price negotiation of ten common prescription drugs taken by millions of people. The drugs selected include Eliquis, Jardiance and Xarelto. Lutes says those pricing provisions are not affected by the president's executive action, as of this report's air 

The Centers for Medicare and Medicaid Services (CMS) says about 8,247,000 people with Medicare Part D coverage use the ten drugs selected for price negotiation to treat conditions like cardiovascular disease, diabetes, autoimmune disease and cancer.

The Source: Information for this report comes from Sadie Tuescher of WI Health Insurance Advocate, Nick Lutes of the Medigap Helpline Program, Marwa Bakr at Infinity Pharmacy, The 2022 Inflation Reduction Act, CMS and KFF.

Contact 6MilwaukeeCudahyNews