Frequently Asked Questions About the Inflation Reduction Act
These Frequently Asked Questions will help provide the information you need to get the most out of your prescription drug coverage.
- The Inflation Reduction Act (IRA) is a federal law passed by Congress in 2022 to help improve Medicare.
- The IRA requires all Medicare Advantage plans to make several changes to Medicare drug benefits across multiple years.
- All MAPD and PDP plans are impacted by the IRA – not just Tufts Health Plan.
Four changes will be made in 2025:
- Maximum out of pocket lowered to $2000 per year
- Implementation of the Medicare Prescription Payment Plan
- Formulary tier changes (Moving drugs to higher tiers as well as some drugs no longer covered)
- Change from copay to coinsurance on Tiers 3 and 4.
In addition, there will be no Coverage Gap stage (donut hole) where members faced 100% of their drug costs. Once a member meets their maximum out of pocket, they pay $0 for covered prescription drugs.
Lower Maximum Out of Pocket
The Rx Maximum Out of Pocket amount will be lowered to $2,000.
- This is good news.
- $2,000 is the most you would pay for your prescription drugs in 2025 before entering the catastrophic phase where Tufts Health Plan pays the prescription drug costs and you pay $0 for covered prescription drugs.
The Medicare Prescription Payment Plan
The Medicare Prescription Payment Plan is a new payment option to help members manage out-of-pocket Part D drug costs by paying in installments across the calendar year (January-December).
- This is good news..
- Members opt-in to receive a monthly bill that splits their prescription drugs cost into regular monthly payments (as an alternative to paying the full amount up front).
- All plans will offer this payment option and member participation is voluntary.
- For example, if you go to the pharmacy in January and your prescription has a $600 copayment you can enroll in the Medicare Prescription Payment Plan to pay nothing to pickup the prescription and instead receive a bill from Tufts Health Plan each month Jan–Dec for $50 (assuming you do not fill any other prescriptions). There is no interest or financing charges for participating in the Medicare Prescription Payment Plan program.
- There is no cost to join the Medicare Prescription Payment Plan
- The monthly bill is based on what you have paid for any prescriptions, plus any previous month’s balance, divided by the number of months left in the year.
- All plans use the same formula to calculate monthly payments.
- Members who have high Part D cost-sharing earlier in the plan year are more likely to benefit from the program by spreading those expenses throughout the year.
- Members who pay more than $600 for a single prescription at the pharmacy.
- Members whose yearly drug costs are low.
- Members whose drug costs are the same each month.
- Individuals enrolled in a 2025 plan can elect the Medicare Prescription Payment Plan program during the Annual Enrollment Period (AEP) (October 15-December 7, 2024) or at any time during the 2025 benefit year.
- There are multiple ways to sign up for the Medicare Prescription Payment Plan:
- Enroll online
- Mail or fax your completed paper enrollment form:
- Fax: 1-617-972-9405
Mail:
Point32Health
1 Wellness Way
MS D3
Canton, MA 02021-9936
- Call Member Services
- Mail or fax your completed paper enrollment form:
- Enroll online
- Several changes will be made to the formulary in 2025.
- These changes will cause some drugs to have higher cost shares and some drugs to no longer be covered.
- For drugs that will no longer be covered, the federal government requires that an alternative medication is available.
- Some higher cost drugs that have a fixed copay will be changing to a coinsurance payment which means you pay a percentage of the actual cost of the drug instead of a fixed copayment.
- The percentage you pay depends on the plan you are in and what type of drug it is.
- For some members, the coinsurance amount will be a similar or lower cost to the current copay amount.
- But the change to a coinsurance payment will mean some members costs at the pharmacy counter will be much higher than the current copay amount.
- In addition, since the actual cost of a drug that the pharmacy buys from the manufacturer can change month to month, the cost to the member at the pharmacy counter may change from one fill to the next.
- Most generic drugs will continue to have low copays that range from $0–$8 per 30-day fill at a preferred retail pharmacy depending on the plan and the drug.
- If your drugs have high costs next year under the new cost share structure, the $2,000 maximum out of pocket and the Medicare Prescription Payment Plan will help make your drugs more affordable.
- The lower maximum out of pocket will protect you from spending more than $2,000 during the year and the Medicare Prescription Payment Plan can be used to spread payments across multiple months during the year.
- Starting in 2025, the donut hole or coverage gap will be eliminated, meaning there will be no more gap in prescription drug coverage.
- If your prescription drug costs reach $2,000 you move to the Catastrophic Coverage Stage where Tufts Health Plan pays your prescription drug costs and you pay $0 for prescription drugs.
While the Medicare Prescription Payment Plan helps to manage costs, it doesn’t lower the costs. However, members may be eligible for the following programs:
- Extra Help
A Medicare program that helps pay your Medicare drug costs if you have limited income and resources. Visit secure.ssa.gov/i1020/start to find out if you qualify and apply. You can also apply with your state’s Medicaid office. Visit Medicare.gov/basics/costs/help/drug-costs to learn more.
- Medicare Savings Program
A state-run program that helps people with limited income and resources pay some or all of their Medicare premiums, deductibles, and coinsurance. Visit Medicare.gov/medicare-savings-programs to learn more.
- State Pharmaceutical Assistance Program (SPAP)
A program that may include coverage for your Medicare drug plan premiums and/or cost sharing. SPAP contributions may count toward your Medicare drug coverage out-of-pocket limit. Visit go.medicare.gov/spap to learn more.
- Manufacturer’s Pharmaceutical Assistance Programs (sometimes called Patient Assistance Programs (PAPs))
A program from drug manufacturers to help lower drug costs for people with Medicare. Visit go.medicare.gov/pap to learn more.
Many members qualify for savings and don’t realize it. They can visit Medicare.gov/basics/costs/help, or contact their local Social Security office to learn more. To find a local Social Security office visit secure.ssa.gov/IC
- See our website for additional details on these changes at thpmp.org/IRA
- Call Member Services. Our Member Services team is here to help answer any questions you have about the prescription drug changes.