2025 Part D plan does not cover my expensive insulin brand … what do I do?

on Nov 21, 2024

Toni:

In 2022, the Toni Says Medicare team enrolled me in Medicare with Medicare Supplement and Medicare Part D plan including my prescriptions that had copay only. When I looked online at Medicare.gov, I noticed that the diabetic insulin I take will no longer be covered for 2025. This change will cost $391 monthly out-of-pocket. And Ozempic, which has an $11 copay in 2024, is a Tier 5 drug costing $238 per month with no copay for 2025.

With Ozempic and the meds I take monthly, I will meet the $2,000 maximum out-of-pocket in February, paying $0 the rest of the year -- except for the $391 for the insulin each month.

Toni, how can I find a 2025 Part D plan that covers my insulin and change the Part D plan before the Annual Enrollment Period (AEP) ends on Dec. 7?

--Tabitha from Lubbock, Texas

Tabitha:

The Toni Says phones began exploding after Oct. 15 (when the AEP started) because Americans with specific brand drugs, such as Ozempic, Mounjaro or diabetic insulins, and other drugs are receiving higher drug costs, or not being covered such as in your situation. This problem is also occurring with Medicare Advantage plans.

Tabitha, enrolling in a Medicare Part D or Medicare Advantage with Part D plan online requires you to open a www.medicare.gov account which you have done because you were able to view what your prescriptions copays were, the tiers Ozempic was placed in, and what the cost of your insulin would be since it is no longer covered under your 2024 Medicare Part D plan.

Changing to a 2025 Medicare Part D or Medicare Advantage Part D plan is an easy process and I will explain how to do it in simple terms:

1. Log in to your www.medicare.gov account and click on “Find health and drug plans.”

2. Verify your “extra help” (based on income), list the pharmacies you prefer; under “Your Drug List,” list ALL of your drugs. Please enter the prescriptions into the system on a monthly basis rather than a 3-month or 6-month basis, because of Medicare’s new $2,000 out-of-pocket maximum rule. Using monthly rates lets you know when you will qualify for the $2,000 out-of-pocket maximum and no longer have to pay the deductible or copay for the rest of the year. (When drugs are input on a quarterly basis, the $2,000 limit is not easy to find.)

3. Click on “Find Plan Now” and click “2025” to find 2025 Part D or Medicare Advantage plans. (Only click “2024” if you are new to Medicare and enrolling in Part D for the first time for a Dec. 2024 start.)

4. Select which plan you wish to enroll in by checking either Medicare Advantage or Medicare Part D (stand-alone).

5. Tabitha, your current enrolled plan will show up first with the 2025 premium. The plans listed after the plan you are enrolled in are rated from the least out-of-pocket to the most out-of-pocket on the Medicare.gov site.

6. Because your brand of insulin is not covered in the 2025 Medicare Part D plan you are enrolled in, search through the prescription drug plans below the current plan to find which Part D plan covers your insulin and your other prescriptions and Ozempic at the lowest copay.

7. Take your time exploring options and selecting the plan that meets your prescription and financial needs, whether choosing a stand-alone Medicare Part D or Medicare Advantage plan.

8. In the drug plans you are exploring, under the section titled “Estimated Total Monthly Drug Cost” it will show when you meet the $2,000 out-of-pocket drug cost.

9. Those with low drug costs and low copays do not have to meet the $2,000 out-of-pocket if the monthly cost is lower.

Readers, you will want to take these steps to ensure that you sign up for your Medicare Part D plan before the AEP ends on Dec. 7.

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Toni King is an author and columnist on Medicare and health insurance issues. She has spent nearly 30 years as a top sales leader in the field. For a Medicare checkup, call the Toni Says call center at (832) 519-8664 or email info@tonisays.com regarding your Medicare plans and options. Toni Says Medicare Survival Guide Advanced edition is available at www.tonisays.com.