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Pharmacies can Rely on Technology to Navigate 2025 Plan and Price Changes

Introduction

Leveraging Technology to Navigate 2025 Plan and Price Changes

Final numbers aren’t in yet, but based on past years, it’s likely as many as 15% of Medicare beneficiaries began 2025 with a new coverage plan, the result of changes selected during last fall’s open enrollment period. This is in addition to the record 24 million consumers who signed up for Affordable Care Act (ACA) marketplace plans, and the untold number of employees affected by changes to the coverage offered through their workplaces. Together, these plan changes affect millions of patients, and coincide with price increases that took effect on January 1 on more than 250 branded medications.

For the nation’s pharmacists who will help patients navigate their new plans, this could mean a significant uptick in questions about coverage, costs, and alternatives. Fueling this expected increase in patient queries are other factors, including core changes to Medicare Part D that will affect all beneficiaries, namely a $2,000 cap on out-of-pocket costs and new payment plan options.

Pharmacies will, of course, embrace the opportunity to assist patients. But responding to these inquiries and accessing the required information takes time, something in very short supply across all pharmacies. Consider results of the most recent National Pharmacist Workforce Survey, in which 56% of pharmacists said they spend up to 10 hours per week consulting with patients about their prescription drug coverage. Nearly 30% of pharmacists said they spend between 11-and-20+ hours providing this information.

Technology though, can help. Technology-based solutions can give pharmacists real-time access to patient plan information, identify less-costly alternatives, handle prior authorizations, locate coupons and rebates, facilitate communication, and ensure meticulous records are maintained. Certain pharmacy management systems, including PrimeRx, can provide all of these solutions from within a single platform. This means no need to install multiple systems or keep track of software upgrades. Instead, all functionality operates smoothly and seamlessly.

Following is discussion about patient-related issues facing pharmacies in the early days of 2025, along with information about the role technology can have in addressing those issues.

Plan Changes Likely to Result in Increased Patient Inquiries

Medicare and ACA beneficiaries who signed up for new coverage plans during last fall’s open enrollment period saw those new plans take effect on January 1. Based on historical performance, this means millions of Medicare and ACA patients beginning the year with new coverage, and likely lots of questions for their pharmacists.

a. Medicare Enrollment – What to Expect in 2025

The Medicare enrollment period affected both traditional Medicare beneficiaries as well as patients enrolled in Medicare Advantage (MA) plans. Analysis by Commonwealth Fund notes that “about one of seven,” or 15%, of beneficiaries have changed their coverage in the past two years. With 67 million Americans currently receiving Medicare coverage, that could amount to more than 10 million patients beginning 2025 with new coverage plans.

Traditional Medicare Plans. Traditional Medicare, also referred to as Original Medicare, provides patients with coverage for both Part A (hospital) and Part B (medical) services. Beneficiaries with traditional Medicare coverage can see nearly any doctor or hospital that takes Medicare, with no network limits or prior approval requirements. Traditional Medicare beneficiaries have the option to purchase supplemental insurance, called Medigap, to help cover additional costs. They also have the option of purchasing a Part D stand-alone plan to cover prescription drugs.

- Stand-Alone Part D Prescription Drug Plans (PDPs) For 2025, the “average Medicare beneficiary,” according to Kaiser Family Foundation (KFF), was able to choose from 14 stand-alone Part D plans. This was seven fewer than the number offered during 2024. Plans varied with regard to premiums, deductibles and cost sharing, medications covered, utilization requirements, and pharmacy access, among other factors.

Medicare Advantage Plans. Medicare Advantage plans, also known as “Part C” or “MA Plans” are offered by private companies that have been approved by Medicare. According to the U.S. Department of Health and Human Services (HHS), a Medicare Advantage plan will typically include all Part A and Part B coverage, with additional coverage for services such as vision, hearing, dental, and/or health and wellness programs. “Most,” HHS notes, “include Medicare prescription drug coverage (Part D).” Each Medicare Advantage Plan sets its own rules for obtaining coverage (i.e., need for a referral to see a specialist or restrictions on which providers/facilities can be accessed) and determines out-of-pocket costs. Beneficiaries were able to choose from 43 Medicare Advantage Plans offered by eight insurance companies for 2025, according to KFF. “These plans vary across many dimensions, including premiums and out-of-pocket spending, provider networks, extra benefits, prior authorization and referral requirements, and prescription drug coverage.”
- Medicare Advantage Prescription Drug Coverage (MA-PD) Medicare Advantage beneficiaries who want prescription drug coverage “must choose a plan that offers this coverage,” explains KFF, adding that “they are not permitted to enroll in a stand-alone prescription drug plan while enrolled in Medicare Advantage. Medicare Advantage plans with drug coverage are called MA-PD plans and for 2025, beneficiaries were able choose from 34 options.

Together, Medicare beneficiaries had an estimated 48 plans with Part D drug coverage from which to choose. This includes the 34 Medicare Advantage plans and 14 stand-alone plans. While beneficiaries were advised to carefully consider cost and coverage elements of each plan, it’s likely that many questions will arise as patients begin to use their new plans and fill prescriptions.

b. Medicare Enrollment – What to Expect in 2025

Consumers who enrolled in ACA marketplace plans during the fall open enrollment period, which ran from November 1 – December 15, began coverage on January 1. This includes an estimated 3.2 million patients who are new to the marketplace, a subset of the record 24 million consumers who selected plans during the open enrollment period. Patients who register during the December 16 – January 15 period begin coverage on February 1.

Much of the growth in marketplace participation is due to the increased number of Americans who are newly eligible for tax credits that has made coverage more affordable. According to HHS, 80% of consumers signing up during 2024 had access to plans costing $10 or less per month. Without the tax credit, KFF notes, an average 40-year-old would pay $497 per month to participate in a “benchmark” silver marketplace plan.

Under the ACA, each state (and the District of Columbia) is required to operate a health insurance exchange, through which residents and small businesses can shop for, and obtain, private health insurance. As noted by the Congressional Research Service (CRS), a state has the flexibility to establish its own state-based exchange (SBE), or have the federal government administer an exchange on its behalf “as a federally facilitated exchange (FFE).” Another option, referred to as an SBE-FP involves a state administering an SBA, but utilizing a federal IT platform.

According to CRS, 30 states have FFEs, 18 states (including the District of Columbia) have SBEs, and three states have SBE-FPs. While each state has flexibility over its exchange, every plan offered must be a qualified health plan (QHP), and must include the 10 essential health benefits (EHBs) mandated by the ACA.

Those benefits include:

•Ambulatory patient service	•Emergency services
•Hospitalization	•Pregnancy, maternity, and newborn care
•Mental health and substance use	•Prescription drugs
•Rehabilitative services and devices	•Laboratory services
•Preventive and wellness services	•Pediatric services

Patients Affected by 2025 Drug Price Increases

Pharmacists should also be aware of – and expect patient queries – about significant changes to Medicare Part D. According to CMS, 2025 brings two major developments, as outlined in the Inflation Reduction Act: A $2,000 cap on out-of-pocket costs and a new payment plan option.

Spending Cap. Effective January 1, all Medicare beneficiaries – traditional Medicare as well as Medicare Advantage patients – can benefit from a $2,000 cap on prescription drug medications. This is expected to affect an estimated 3.2 million Medicare recipients, especially seniors who take multiple medications or rely on high-cost medications, according to analysis by AARP. Details about the program include:

- The cap only applies to medications that are included on a patient’s drug formulary. This means a patient should be careful to ensure that prescribed medications are on their formulary.

- The new cap effectively eliminates the coverage gap, referred to as “the donut hole,” that affected millions of beneficiaries. According to CBS News, the coverage gap occurred when beneficiaries reached a point where they had spent more than $5,030 on drug costs, but had yet to reach the $8,000 threshold at which point catastrophic coverage took effect.

Prescription Payment Plan. A new Medicare prescription payment plan also took effect on January 1. This provides patients the option of using a payment plan to spread out their medication costs. According to CMS, Part D beneficiaries now have the option to pay out-of-pocket prescription drug costs in the form of capped monthly payments instead of all at once at the pharmacy. A few program details include:

- Costs can be divided into monthly payments, and may not be subject to interest or fees.

- The new benefit is available to all Medicare Part D and Medicare Advantage Plan beneficiaries, and beneficiaries may opt into the program at any time.

- Program participants will pay $0 to the pharmacy for covered Part D drugs. Instead, patients will receive a monthly bill from the plan sponsor.

- Pharmacies will be paid by the Part D sponsor.

- Plan sponsors are required to notify the pharmacy when “one of their Part D enrollees incurs out-of-pocket costs for covered Part D drugs that make it likely the individual may benefit from the program.” This may include patients who take a drug that costs $600 or more, which is the threshold set for identifying patients likely to benefit from enrollment in a payment plan. “The pharmacy will provide the Part D enrollee with the Medicare Prescription Payment Plan Likely to Benefit Notice which, according to CMS, is a “standardized notice that all Part D sponsors are required to use.”

Responding to 2025 Changes with PrimeRx - Technology-Based Pharmacy Solutions

These changes come as pharmacists already face challenges that compete for time and attention. Among other things, pharmacists must contend with decreasing reimbursement rates, a situation that become somewhat bleaker when the U.S. Congress, in the final hours of the 2024 legislative session, failed to impose hoped-for reforms on pharmacy benefit managers (PBMs).

Technology has kept pace though, with targeted solutions that address real-time pharmacy needs. This includes the PrimeRx pharmacy management system, which offers comprehensive functionality presented in a logical, highly user-friendly format. Essential capabilities include:

Prescription Benefit Review. PrimeRx includes direct integration with the Real-Time Prescription Benefit from Surescripts solution. The solution provides real-time information about a patient’s covered medications. This in turn allows the pharmacist to determine if a prescribed medication is covered, and the patient’s copayment. Should a medication not be covered, or require an expensive copay or prior authorization, the solution may suggest more appealing alternatives.

Pharmacists can rely on this solution to help patients understand coverage and cost components of their new plans. This information will allow patients to determine if a new plan is suitable for their health and medication needs, or if perhaps an alternative plan should be selected. And for Medicare beneficiaries, the Real-Time Prescription Benefit solution ensures medications are included in a patient’s formulary, and will count toward the $2,000 out-of-pocket cap.

The Surescripts solution automates the benefits review process, and eliminates time-consuming phone calls between pharmacists, plan representatives, and physicians’ offices.

Drug Cost Comparisons with PrimeRx Market. Pharmacies can help manage increases to medication costs by ensuring low-cost pricing for all drug purchases. PrimeRx Market, offered by PrimeRx, makes the process easier than ever.

PrimeRx Market is an online platform that connects pharmacies with medication suppliers with benefits that include:

Direct access to more than 40 drug wholesalers and suppliers. PrimeRx Market is the industry leader when it comes to the number of participating suppliers. Pharmacists can easily compare prices, identify best sources for different types of drugs, and seamlessly submit orders with multiple providers.

Single-source solution for all medication/inventory needs. Pharmacies can shop for a wide range of medicines including brand-name drugs, generics, and over-the-counter products, among other offerings.

Fast, accurate results. Pharmacists no longer have to spend time checking with multiple suppliers to identify the best pricing for a specific drug. Instead, PrimeRx Market generates a comprehensive side-by-side comparison of each supplier’s pricing for a requested drug. The system generates immediate results in a user-friendly format.

Seamless ordering capability. Once a preferred supplier is identified, the pharmacy can submit an order, without leaving the PrimeRx Market platform.

As pharmacies sort through the impact of recently announced price increases, affecting more than 250 medications, PrimeRx Market will ensure all medications are obtained at the lowest cost, and with the highest levels of ease and efficiency.

Medication Affordability — eVoucher and Denial Conversion Services. PrimeRx addresses medication affordability with solutions that address claims denials and excessive copay amounts. Together, these solutions help pharmacists ensure their patients leave the pharmacy with the medications they need, at a price they can afford.

The eVoucher services solution operates at point of sale. The software automatically identifies and applies manufacturer co-pay coupons, providing immediate relief to patients in the form of reduced out-of-pocket costs.

Denial Conversion Services. Prime Rx pharmacies can ensure patients receive their preferred medications, while also generating revenue by participating in Micro Merchant Systems’ Denial Conversion Services program. The program allows pharmacists to provide patients with their prescribed medications – even if the claim has been rejected by the payer.

The program converts a denied claim to “paid” status, thereby allowing the pharmacy to dispense the medication. Micro Merchant Systems, the company behind PrimeRx, reimburses the pharmacy for the cost of the medication and also pays the pharmacy a transaction fee.

Patient Communication. Accurate, timely communication is essential to helping patients understand changes affecting their prescription drug access. PrimeRx allows pharmacies to seamlessly generate emails and text messages with capabilities that include:

Targeted Messages. Pharmacies can generate messages for dissemination to select groups of patients. This may include, for example, a notice about the new Medicare payment plan option sent to patients with medications that meet the $600 threshold. Or a reminder to all Medicare patients about the importance of reviewing their plan’s drug coverage components.

Personalized Messages. PrimeRx can also transmit messages that address a patient’s unique health needs. This can include everything from a link to schedule a needed vaccination, to a notice with updated guidance on a particular chronic condition. And most personal of all – the system can send a “Happy Birthday” message on a patient’s big day!

Automated Refill Messages. PrimeRx will also send automated reminders when a refill is required, and when a prescription is ready for pickup. In addition, pharmacies can receive a patient’s “opt-in” for participation in an automatic renewal program, thus satisfying an important compliance requirement.

Workflow Optimization. The PrimeRx management system helps pharmacists save valuable time by automating key pharmacy workflows including prescription intake, dispensing, refills, inventory management, and claims processing, among others.

While technology will never eliminate entirely the need for human oversight, the solution dramatically reduces the time required to perform critical tasks. A few examples include:

Electronic prescriptions arrive seamlessly and are automatically validated and added to the dispensing queue.

Labels are generated, with special accommodations available for braille, large print, or other patient needs.

Inventory levels are automatically updated each time a medication is dispensed, and each time new supplies are added.

The solution automatically transmits a claim to the appropriate payer and tracks the claim until a response is received.

And critically important, the solution updates patient records each time a prescription is filled, and to reflect clinical services administered, as well as pharmacist-patient discussions.

Extensive Patient Records. In addition to medication histories, PrimeRx allows the pharmacist to maintain extensive records for all patient interactions. This includes observations and notes following each patient interactions, along with information about a patient’s health history including immunizations, point-of-care testing, lifestyle/habits, and living arrangements. All information is stored within PrimeRx and can be seamlessly accessed and updated.

Report Generation. Pharmacy managers can have real-time visibility into all pharmacy operations and generate comprehensive reports detailing activity on essentially any aspect of pharmacy operations. Reports can be customized based on a preferred topic and reporting period. Extensive reporting allows insight with regard to patient demographics and plan enrollment. Pharmacy managers can track performance across self-selected metrics, which provides an opportunity to identify areas of strong performance, along with opportunities for improvement.

Conclusion

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“CMS Releases 2025 Medicare Part D Bid Information and Announces Premium Stabilization Demonstration,” Centers for Medicare & Medicaid press release, July 29, 2024.
Cottrill, Alex; Niniek, Jeannie Fuglesten; and Cubanski, Juliette, “What to Know about the Medicare Open Enrollment Period and Medicare Coverage Options,” KFF, September 26, 2024.
Cubanski, Julliette and Damico, Anthony, “Medicare Part D in 2025: A First Look at Prescription Drug Plan Availability, Premiums, and Cost Sharing,” KFF, November 22,2024.
Erman, Michael, “Drugmakers to raise US prices on over 250 medicines starting January 1,” Reuters, December 31, 2024.
“Fact Sheet: Medicare Prescription Payment Plan Final Part One Guidance,” Centers for Medicare & Medicaid Services, February 2024.
Forsberg, Vanessa C., “Overview of Health Insurance Exchanges,” Congressional Research Service, March 17, 2023.
“HealthCare.gov Breaks New Record with 16.6 Million Consumers Signing Up for Coverage – the Highest Ever for January 1 Coverage,” Centers for Medicare & Medicaid Services press release, December 20, 2024.
Leonard, Faith; Shah, Arnav; and Jacobsen, Gretchen, “Open Enrollment Allows Medicare Beneficiaries to Change Coverage – How Many Are Switching and Why?” Commonwealth Fund, December 2, 2024.
Murphy, Alexandra, “Drugmakers plan price hikes for 250+ medications in 2025: Reuters,” Becker’s Hospital Review, December 31, 2024.
“Nearly 24 Million Consumers Have Selected Affordable Health Coverage in ACA Marketplace, With Time Left to Enroll,” Centers for Medicaid & Medicare press statement, January 8, 2025.
“New Medicare Part D Out-of-Pocket Spending Cap is an Important Improvement for Enrollees Facing High Prescription Drug Costs,” AARP Public Policy Institute, August 2024.
“Original Medicare (Part A and B) Eligibility and Enrollment,” CMS.gov, October 10, 2024.
“Parts of Medicare,” Medicare.gov, accessed January 8, 2025.
Picchi, Aimee, “Medicare’s new $2,000 prescription drug cap goes into effect. Here’s how it works,” CBS News, January 2, 2025.
“Plan Year 2025 Qualified Health Plan Choice and Premiums in HealthCare.gov Marketplaces,” Centers for Medicare & Medicaid Service, October 25, 2024.
Twenter, Paige, “Medicare’s $2K drug cap starts Jan. 1,” Becker’s Hospital Review, December 27, 2024.
“What Marketplace health insurance plans cover,” HealthCare.gov, accessed January 10, 2025.
“What is Medicare Part C?” U.S. Department of Health and Human Services, July 22, 2024.

References

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Abelson, Reed and Robbins, Rebecca, “The Powerful Companies Driving Local Drugstores Out of Business,” The New York Times, October 19, 2024.
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“Competition, Consolidation, and Evolution in the Pharmacy Market,” The Commonwealth Fund, August 12, 2021.
Cubanski, Julie and Neuman, Tricia, “Prices Increased Faster Than Inflation for Half of all Drugs Covered by Medicare in 2020,” KFF, February 25, 2022.
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With PrimeRx, pharmacy workflow tasks can be automated, leaving more time for pharmacists to engage with patients and focus on other pharmacy matters.