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By: Vilmar Trinta Negrón | Interview by: Alied Rivera
Medicare will implement several changes in 2025 aimed at reducing costs for a wider range of medications, establishing a cap on out-of-pocket expenses, and eliminating the coverage gap known as the “donut hole”.
These changes, driven by the Inflation Reduction Act of 2022, aim to simplify access to medications, provide savings for beneficiaries, and improve service efficiency.
Recently, the federal government announced a historic agreement with pharmaceutical companies to lower prices for ten of the most expensive and commonly used medications covered by Medicare, which treat conditions like heart disease, cancer, and diabetes.
The new prices for medications like Eliquis, Xarelto, Januvia, Jardiance, Enbrel, Imbruvica, Farxiga, Entresto, Stelara, and Fiasp will take effect in 2026. For example, the price for the rheumatoid arthritis drug Enbrel will drop by $4,751, a 68% reduction. The price for Stelara, used for psoriasis and Crohn’s disease, will decrease by $9,141, or 66%. Medicare expects to continue adjusting prices over the coming years.
This effort, along with the $35 monthly copay cap for insulin products that thousands are already benefiting from, represents a significant step toward making treatments for common and chronic conditions more affordable.
“The reduction in drug prices can free up funds in the health budget, allowing resources to be redirected to other services or needs. Cost-effective management of treatments will help to expand coverage for other services that are currently excluded because medications consume the entire budget. It’s crucial for both primary care doctors, who monitor recurring conditions, and specialists to keep this in perspective, educate their patients, and inform them about the impact of these changes on other services”, explained Rivera.
For instance, one of the biggest challenges for the aging population is transportation to medical appointments. The savings will allow insurers to provide more rides perhaps 10, 15, or even unlimited instead of just five, addressing other social needs that affect health.
Recertification of Beneficiaries:
The annual recertification process for Medicaid and Medicare that started this year will continue to be a significant challenge in 2025. Although deadlines have been extended for beneficiaries to complete the process, data from the Department of Health indicates that around 175,000 eligible individuals have not yet done so. Communication from doctors to patients about the importance of completing recertification to ensure the continuity of their health coverage is crucial. Failure to comply may result in loss of eligibility, affecting access to essential health services.
Open Enrollment Period:
According to the Puerto Rico Health Insurance Administration (ASES), the open enrollment period for the Vital program will be from January 1, 2025, to February 14, 2025. Beneficiaries are encouraged to stay informed and be prepared to exercise their right to choose or switch insurers during this period.
Reference: Centers for Medicare and Medicaid Services
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