Do you know about the upcoming Medicare changes to migraine medication coverage in 2025? Are you confused or worried about figuring out if this change is a good or a bad thing? Not sure if you have to do anything next month when Medicare plan selection starts for 2025? If so, you’re not alone! The Inflation Reduction Act is being implemented in stages over a few years, and the great news is that the January 2025 change is likely to be a lifeline for many people with migraine or other headache disorders who are also on Medicare!
Why Has Medication Access Been An Issue?
Many of us have felt confused, angry, and even stigmatized at the lack of access to the new migraine medications. People with commercial health insurance plans have been able to utilize much-needed co-pay programs run by pharmaceutical companies to gain immediate access to the new CGRP inhibitors and other new medications such as Trudhesa, Elyxyb, and ReyVow. For many, these medications have been life-changing for people with migraine. However, for others, the out-of-pocket costs are simply too high to be feasible.
Due to Federal regulations, people with Medicare coverage (and other government-run insurance programs) are barred from utilizing pharmaceutical-run co-pay programs. While a few pharmaceutical companies have foundations that offer “Medication Access Programs” for those who are uninsured, underinsured, or on programs such as Medicare, even those options are limited. They are few and far between, and often have complicated or personally invasive hurdles to overcome in order to be approved and access the migraine treatment you need.
The result? Many of the people who are MOST impacted by migraine and other headache disorders, such as those who are disabled and on Medicare, have not had access to desperately needed treatments that prevent and treat migraine!
What Is Changing with Medicare in 2025?
The good news is that things are changing as of January 1, 2025. If you are on Medicare, or will be starting Medicare in 2025, you need to know about it!
- First: people on Medicare who opt into the Part D prescription program will have their out-of-pocket prescription costs capped at $2,000 per year! That may sound a lot to some of you, but many migraine medications are priced at around $1,000 per month. And, often more than one prescription is needed, so this will literally change many people’s lives. Add to that the comorbidities common with chronic migraine and the prescriptions required for those conditions; the cost of drugs will no longer be an insurmountable hurdle for as many people.
- Second: In case your immediate thought is: “How will I be able to afford the first $2,000 though?!” There is more good news. The new “Medicare Prescription Payment Plan” will help make that manageable by spreading that cost evenly over 12 months. You can learn more about this on the Alliance for Patient Access website HERE. The AfPA has compiled an informative summary guide about the Medicare Prescription Payment Plan that can be downloaded and printed.
What Do I Need To Do?
If you have Medicare, you likely realize that open enrollment starts on October 15 each year. When you enroll with your choice of Medicare plan, you must opt into the Medicare Prescription Payment Plan directly with your Medicare Part D sponsor. For example, if you have one of the United Healthcare AARP Medicare Advantage Plans, you must opt-in to the payment plan with United Healthcare Medicare Advantage. There does not appear to be a deadline to opt-in, so if you miss doing that this October, don’t worry. You should be able to opt-in at any time during 2025.
Of course, if your income is low, you may be eligible for the currently existing Extra Help Program. This program reduces the cost of your prescription medications, monthly premiums, and annual deductibles. If your income is too high to qualify for the Extra Help Program, but you meet Social Security’s definition of disability AND are working part-time there is another options to explore. You MAY be eligible for a program called the Medicaid “250% Working Disabled Program.” This is a state-run program, and you can apply at your local county social services department. Warning: you will likely have to jump through hoops to qualify for the Working Disabled Program, and don’t expect the first person you speak to at your social services office to know anything about it!
In summary, this is all good news for many of us. With all the stress and frustration felt, especially over the last 6 years trying to gain access to potentially life-changing medications, this is something that hopefully will bring a smile to your face!
Let Us Know…
Are you on Medicare and had trouble accessing the new medications for migraine? If so, how has that impacted your life?
When are the Part D formularies from different companies available? Or will there be no choice?
Super helpful summary! Thanks Shosh!
Glad it was helpful for you!