(NewsNation) — Say goodbye to the doughnut hole. Medicare’s annual gap in coverage of prescription drugs will disappear under changes to the government’s health insurance for seniors.
“It’s the first time in the history of the Medicare program that people have a cap on how much they could have to pay out of pocket,” said Dr. Meena Seshamani, director of the federal Center for Medicare, in an interview with AARP.
“Such a significant change means that in open enrollment, it is so important to shop. Because with such big changes, there very well could be a plan that better suits your health and financial needs,” Seshamani added.
The doughnut hole’s demise is one of many changes to Medicare coverage that recipients should know as the Medicare open enrollment period begins Tuesday and runs through Dec. 7.
What happens during Medicare open enrollment?
The nearly two-month window allows you to switch from original Medicare to a Medicare Advantage plan, or vice versa; change from one Medicare Advantage plan to another; change from one drug plan to another; or quit your Medicare prescription drug coverage altogether.
The changes affect Medicare Advantage, the private plans that supplement the government’s bedrock health care insurance, and Medicare Part D, the plans that help cover prescription drug expenses.
Here are some of the notable changes for 2025:
How is the Medicare ‘doughnut hole’ disappearing?
Starting next year, the supplemental prescription drug insurance plans known as Medicare Advantage will include a $2,000 cap on out-of-pocket payments for deductibles, copayments and coinsurance for covered drugs.
That will eliminate the “doughnut hole,” the term used to describe when a drug plan would stop coverage after expenses reached $5,030, then resume under “catastrophic coverage” status at $8,000.
But the $2,000 cap doesn’t include premiums, and some Medicare Advantage insurers may raise their premiums. It’s a good idea to calculate whether the higher premium wipes out the potential doughnut hole savings.
Medicare Advantage plans may start covering Wegovy and Ozempic
The new year lets insurance companies take advantage of a March decision by the Food and Drug Administration to approve Wegovy for overweight people with cardiovascular disease.
Part D plans are already permitted to cover Ozempic and Mounjaro for Type 2 diabetes but are prohibited from covering drugs designed just for weight loss. That keeps another drug, Zepbound, off the coverage list. But the FDA is considering approving the drug for treating moderate to severe sleep apnea. If that happens, Part D plans could cover Zepbound for that purpose.
Medicare Advantage plans must update your status
Can’t keep track of where you stand when it comes to available benefits? Medicare Advantage plans will now send you a midyear statement that will list what benefits you haven’t used.
Medicare Advantage plans tout their extras like dental, vision and fitness benefits when they pitch your business. But many people forget to use those extras, so the midyear update may spur you to schedule that hearing test you’ve put off.
You can compare Medicare plans at Medicare.gov. The comparisons include coverage, cost and quality ratings “to help you see the real differences between plans and feel confident in your choice,” according to Medicare’s open enrollment fact sheet.
Medicare offers variety of options to help you make a choice
There are multiple ways you can get information to help choose a Medicare plan:
- By phone: 1-800-MEDICARE (1-800-633-4227)
- TTY: 1-877-486-2048
- State Health Assistance Programs
- Part D Extra Help (for those making less than $22,000/year)