Medicare Caps Patient Drug Spending, What That Means For You

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Medicare Caps Patient Drug Spending, What That Means For You

In the world of Medicare, things are always changing. What does that mean for you? Well the news is always different for everyone. For example, it was recently announced that beginning in 2025, there will be a cap on patient drug spending. Patients will have a $2,000 cap on prescription drugs. This is great for many who are worried about the rising costs of their medication.

The news was made as part of an ongoing effort to make Medicare more affordable for it’s users, not only with the cost of the coverage, but what the out of pocket costs could be for each person. While some may not come close to $2,000 out of pocket, for others, that cap could be hit earlier than expected. That’s why this news will be helpful to some more than others but it is still a very big deal for those who are seeing their costs go up too fast.

What Does The Spending Cap Cover?

Because the spending cap is part of a large list of announcements for upcoming changes to Medicare policies, it will not impact much for users before 2025. Additionally to the $2,000 cap, users will also have the option to cover their prescription costs monthly or at different times throughout the year. While this may not make a difference in spending, it could make a big difference for those who get their retirement funds sporadically and are struggling with the monthly costs.


When working with a Medicare advisor, it’s always important to discuss what your financial situation is if it limits the type of coverage you can afford. This information will help them to create a custom package based on the options that are available from different providers as well as what areas you feel you need the best coverage in. Expanding your options of providers is a great way to expand the options you have available which is why you always want to work with an independent advisor.

Who Is Eligible?

The spending cap will only be a benefit for those who are on a prescription drug coverage plan. The cap will not apply to anyone who is on Medicare but does not have the prescription drug coverage, nor any other types of insurance that typically cover their medication costs. This example is more common with seniors who are still working and receiving health insurance coverage from their employer. While they are able to take advantage of their free Medicare along with their employer provided coverage, they are not eligible for benefits and policy changes for the supplemental plans.

For seniors between the ages of 65-70, this is a common area of confusion. Yes, while receiving Medicare coverage you are eligible for all the options and benefits offered under that specific plan. However, in order to receive full options and benefits, you must include supplemental coverage on things like dental care, prescription drug costs and so forth.

What About Your Medications?

While this cap will not be applied until 2025, there are some immediate impacts you may feel. One of the reasons for these policy changes is that Medicare is looking to expand it’s ability to use new drug companies and other vendors to provide care and whatever else is needed for its users. Because of their low selection of drug companies in the past, costs have gone up rapidly and availability has also become an issue. Moving forward, pharmacies and users will be able to select from more options, making it more affordable to get the medication you need while also having access to more options.

This is another example of great news for some, not so great for others and will depend on the medications you are on, if changes are made as far as the manufacturer and so forth. This is where working with your advisor, as well as your local pharmacies can be a big difference. Knowing what options you have for medications can help you pick and choose which pharmacies you shop with, especially if one carries a manufacturer you prefer and the other does not.

What To Look Over In 2023

If you are not sure what to expect as far as changes from your coverage, costs or anything else, make notes and keep receipts. It’s important to know what your options are, especially if they are changing in the future. If you can increase the benefits you are getting from your plans without increasing costs, that is a big advantage and something that everyone needs to consider when they are working with their advisor on selecting a provider.

It’s important to also consider the fact that your costs may fluctuate next year for over the counter medicines as well. Many believe that the cost for these medications is becoming worse than those of prescription drugs. Because of this, there is the option to utilize the prescription drug plan you are enrolled in to get prescriptions from your doctor that may treat some of the symptoms or conditions you usually get the OTC meds for. If they work as well or better and are more affordable, there are too many advantages to ignore.

Over the last several years, Medicare users have focused more on the cost of personal care and prescription drug costs and availability more than many of the standard services they have grown accustom to. That’s because in-person care and coverage continues to be a strong area of the plans. However, not being able to stabilize costs for medications has given many users a difficult time in guessing their expected costs for the upcoming years, thus making it difficult to know what a monthly budget would be.

Having the ability to change when you pay as well as having a cap on your annual costs makes getting the right medications easier and more affordable than in the past. The hope is that additionally, with this cap, that these policies will help those who have supplemental coverage to save even more money. If you are enrolled in Medicare but are not sure about supplemental coverage, contact an advisor today.

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