CMS is phasing in the Manufacturer Discount Program for certain drugs of qualifying drug manufacturers over the next several years. The phase-in for the initial coverage phase will occur from 2025 through 2028 and that of the catastrophic phase will occur from 2025 through 2030. For any drug subject to the phase-in, Part D sponsors must pay the additional cost that would have otherwise been covered by the manufacturer discount.

Modified Medicare Part D TrOOP Categories

The IRA also updated what counts toward the True Out-of-Pocket Cost (TrOOP) for CY2025. TrOOP includes costs the beneficiary pays out of pocket for their prescriptions (e.g., their deductible, copayments, and coinsurance) along with select other payments made on a beneficiary’s behalf (e.g., State Pharmaceutical Assistance Program payments, AIDS Drug Assistance Programs). Premium payments do not count toward TrOOP.

For 2025, you’ll see these TrOOP changes:

• Now Included: Payments for previously excluded supplemental benefits provided by Part D sponsors and Employer Group Waiver Plans (EGWPs)
• Now Excluded: Payments under the new Manufacturer Discount Program

Currently, payments under the Medicare Coverage Gap Discount Program count toward TrOOP. That program is being replaced by the Manufacturer Discount program.

Since TrOOP determines when your client enters the initial coverage phase, qualifies for the Manufacturer Discount Program, reaches the annual OOP threshold, and enters the catastrophic coverage phase, these changes could affect the speed with which your client moves through coverage phases.

Medicare Prescription Payment Plan (M3P)

Although your clients’ OOP costs will be lower, they’ll still owe up to $2,000 out of pocket. Starting in 2025, Part D enrollees will have the ability to manage these costs in the form of capped monthly payments. The Medicare Prescription Payment Plan means your clients won’t have to pay upfront and in full at the pharmacy for their covered drugs.

WORK WITH AN MEDICARE AGENT WHO FOLLOWS THE RULES

NOTE: Marketing representatives are prohibited from making unsolicited contact, including through:

• Door-to-door solicitation, including leaving leaflets, flyers or door hangers at a resident or on someone's car
• Approaching beneficiaries in common areas, such as parking lots, hallways, lobbies or sidewalks
• Telephonic or electronic solicitation including leaving voicemail, text messaging or email message (without unsubscribe) or through messages via social media.