Rosemary Maxwell (00:00):

There are going to be drugs where it's very important to get the exact drug prescribed by your doctor right away, and there could be clinical health problems caused by a delay in getting the right drug. So those are the times when I think it's really important for the doctor and the patient and the patient's family to push back as soon as they can.

Introduction (00:22):

Welcome to BrainStorm by UsAgainstAlzheimer's, a patient-centered nonprofit organization. Your host, Meryl Comer, is a co-founder, 24-year caregiver, and Emmy Award-winning journalist, and the author of the New York Times bestseller, Slow Dancing With a Stranger.

Meryl Comer (00:42):

This is BrainStorm, and I'm Meryl Comer. Now through December 7th, we are all being asked to become insurance experts on Medicare open enrollment with most changes taking effect January 1st. This is not simply an administrative deadline. Plans can change premiums, drug coverage, provider networks, pharmacies, and benefits from year to year. Today, we're going to try to cut through the confusion and fine print to focus on what has changed in the Medicare Part D prescription drug benefit coverage and what families need to reconsider during plan selection. Joining me are two experts who understand both the policy and the consequences of getting it wrong. Rosemary Maxwell is counsel in Arnold & Porter's Washington, D.C. Office where she focuses on healthcare, public policy and compliance, including Medicare Part D coverage. Also joining us, Monique Nolan, an attorney at Arnold Reporter with more than two decades of health regulatory experience and formally at the US Department of Health and Human Services focused on Medicare and Medicaid.

Meryl Comer (02:03):

Rosemary and Monique, thank you for joining us today. Rosemary, I want to start with you. What changes to Medicare Part D in 2026? What have they meant and what are the projections for 2027?

Rosemary Maxwell (02:19):

I think the most important change in Medicare Part D, it's a result of the Inflation Reduction Act, which was enacted in 2022. But as of 2025, that statute set a cap on all the out-of-pocket costs that a person could incur for Medicare Part D drug costs. And in 2025, that cap was $2,000. In 2026, the cap was $2,100. In 2027, the cap will be $2,400. And it'll go up with inflation every year. And that might not sound like a big deal, but for certain people, like, depending on which drugs you're taking that are Medicare Part D drugs, that could be a big, big relief, that cap on your annual Part D drug costs.

Meryl Comer (03:14):

Rosemary, this annual cap becomes an important protection for people with complex chronic illness who take multiple medications or even one high cost specialty drug. But what is the vital caveat in the phrase, quote, "Covered Part D drugs"?

Rosemary Maxwell (03:31):

It's a really important phrase, Meryl. , I'll talk about a couple of those vital caveats. First of all, a drug that is covered by Medicare under Medicare Part A or Medicare Part B is not a covered Part D drug. Part A is basically inpatient hospital stays so that, that's not very many of the, that's not the outpatient drugs that you take. And then Medicare Part B covers a very limited category of outpatient drugs. Mostly it covers drugs that are infused or injected in a physician's office or in another healthcare setting. So largely Part D is drugs that are dispensed at the pharmacy, retail pharmacy drugs. The other caveat that's important about Medicare Part D covered drugs is you get your Medicare Part D benefits by signing up with a Part D plan. And Medicare Part D plans are not required to cover every dr- drug that can be a Part D drug.

Rosemary Maxwell (04:38):

So you need to check and make sure that the drugs that you take are on your Part D plan's formulary. It's not a covered Part D drug and it does not count towards your cap if it's not on your, if it's not covered by your plan.

Meryl Comer (04:54):

Let me get this straight, Rosemary. What does not count for the cap if a medication is not on the formulary and has not been approved through an exemption or appeal?

Rosemary Maxwell (05:05):

Yes. And if you go to your pharmacy and you just purchase a drug and pay for it yourself because it's not on your plan's formulary and you haven't gotten coverage of it through an exception or an appeal, that does not count towards your cap.

Meryl Comer (05:22):

Monique, why can two Medicare beneficiaries taking the same medication face very different costs? Can you walk us through the variables?

Monique Nolan (05:34):

Sure. And I think Rosemary, touched on this a bit. , You may have similar, prescription drugs, but it's really going to depend on the plan that you've selected, which will dictate what might be covered or not covered on the formulary. , There can be differences that are patient specific in terms of medical necessity, but that's going to be really the, the, the driver of what would determine, differences, between seemingly si- similarly situated beneficiaries.

Meryl Comer (06:05):

Is it fair to say that a person can make a reasonable choice in December and still get blindsided at the pharmacy in January?

Monique Nolan (06:13):

Well, hopefully not. , We would like to think that Medicare provides sufficient information in the plan finder and other resources from beneficiaries, but I think you're touching on a very important point is that you have to be very thoughtful and almost methodical in looking at what plan would be most beneficial to you given your set of, conditions and needed medications.

Rosemary Maxwell (06:40):

You have to check, not just if it's on the formulary, but drugs can be on the formulary and still be subject to prior authorization or step therapy. So it could be that this drug that you're, you've just been prescribed is subject to prior authorization, and it's not authorized for you. It could be the plan only authorizes coverage of the drug for people with certain conditions or in a certain demographic category and you don't get coverage of it unless you seek an appeal and are successful in doing that. So that's a really important limitation. I mean, I don't want to make it sound like Part D is a trap or anything like that, but that is an important limitation to keep in mind.

Meryl Comer (07:26):

Rosemary, for people living with Alzheimer's disease and other serious chronic diseases, prescription drugs are not optional. What if a plan comes with a formulary that doesn't work for the medicines a person actually needs?

Rosemary Maxwell (07:43):

It's some work to try to get the right plan, but that's the most important upfront protection. And then after that, if it turns out the plan doesn't cover a drug that's really important, you would want to go through an exceptions process and try to get coverage of a drug the plan otherwise would not cover. The other thing is, and you know, this might be important in Alzheimer's, is there are certain drugs, like I said before, that those are Part B drugs and you don't need to worry about Part D coverage.

Meryl Comer (08:16):

Monique, if a person starts January with a high cost medication, it's possible that they'll reach that cap of $2,100 cap very quickly. What should families do now to prepare for that kind of upfront loaded expense?

Monique Nolan (08:34):

Yeah. So there, are certain, options that, Medicare, has offered patients. One of them is what's called the Medicare Prescription Payment Plan. , Previously it was referred to Part D smoothing process. , That's something important for enrollees to understand and consider. , Essentially what that allows you to do is to spread out your out-of-pocket prescription drug costs into monthly installments throughout the year instead of having to pay a large lump sum at the pharmacy. , Under the Medicare prescription payment plan, essentially you would, if you opt for this, approach, you would pay your drug plan sponsor monthly for your cost sharing and pay nothing at the pharmacy counter. , But this is an entirely voluntary, program, but it is not necessarily, suitable for everyone. And it's important for an enrollee to assess whether it's right for them. , For example, this might be a very good option if, as you said, you have high-cost drug sharing, cost sharing, towards the beginning of the year.

Monique Nolan (09:52):

Spreading things out across the year could make things much more manageable, but I just want to emphasize, this program does not lower your total, yearly out-of-pocket costs. It just breaks up, things across the year in terms of, your, your cost sharing. But it may not be a good option for certain enrollees. , There are ones who are eligible for what's called the low income subsidy or extra help. And that is, something that could be more advantageous than the Medicare prescription payment plan. This program started in its most current form in 2025. , And our understanding is that there's been very low adoption so far by beneficiaries, which, we attribute probably because of lack of awareness and then also, likely, a lack of understanding of how the program works.

Meryl Comer (10:47):

Rosemary, let me ask you, Part D also includes projected drug classes, including antipsychotics. Now, for a family caring for someone with Alzheimer's disease-related psychosis, that sounds very reassuring, but what does "protected class" actually mean, and what doesn't it guarantee?

Rosemary Maxwell (11:09):

Very generally speaking, the protected classes policy requires that every Part D plan cover all or most substantially all of the drugs in those six protected classes. And those six protected classes are anti-psychotics, antidepressants, anticonvulsants, HIV, AIDS drugs, drugs for anti-convulsants for epilepsy, and then immunosuppressants that are designed to help, prevent rejection of transplanted organs. The plan is supposed to cover all the drugs in those six categories. So if you need a drug in one of those six categories, you should be able to get coverage of that drug. There, there are some limited restrictions that plans can put on those drugs. They can do prior authorization and step therapy with those drugs. But generally speaking, you should be able to obtain coverage of those drugs because those are drugs that CMS thinks, you know, if those drugs are not available to Medicare Part D beneficiaries, it could really limit their choices.

Meryl Comer (12:20):

Monique, when a prescriber discusses an antipsychotic or another medication for Alzheimer's disease-related psychosis, what should families ask about the Medicare plan before the prescription is filled?

Monique Nolan (12:34):

I think, understanding, again, the scope of the plan's coverage. , As Rosemary said, these are protected classes, but there could be conditions that a plan could put on, and understanding those potential limitations would be something to discuss with the provider, as well as whether, in the provider's view, there are specific, aspects of the individual patient's, medical history that would further support medical necessity related to having access to those types of, drugs.

Meryl Comer (13:08):

As a former physician, Monique, <laugh> Medicare allows beneficiaries and prescribers to request coverage exceptions. Now, what should the clinician's supporting statement say when a family needs a formulary exception for an antipsychotic or other medication intended to address serious symptoms related to dementia?

Monique Nolan (13:32):

Physicians and other prescribers are probably very well versed in what that particular patient needs. , It is important to consider Medicare rules and guidelines around what plans can do, with respect to those exceptions. But in, in general, I think communicating with, the patient and really understanding the individual's unique circumstances are going to sort of dictate what would support, requests for those types of exceptions. And, under Medicare, there, there generally, is a desire, by the agency to, to defer to the clinician their expertise. , And, you know, I think they're, they're wary about plans somehow using that as a way to circumvent those rules and, and prevent access.

Meryl Comer (14:21):

So Rosemary, how specific should the documentation be prior, about prior treatment attempts, adverse effects, failed alternatives, patient safety, caregiver safety, hospitalization risks? I mean, the list goes on, and the consequences of delaying treatment. I

Rosemary Maxwell (14:40):

Think it's important that to the extent that the doctor can do this, the doctor should be able to say that the other drugs that are on the plan's formulary in the same class are either not going to be effective for that patient and explain the rationale for why those drugs won't be effective for the patient, or that the drugs will have adverse effects for that patient.

Meryl Comer (15:08):

Let's play that out a little bit more. If a plan favors a less expensive drug, when would you recommend that a clinician and family push back because the lower cost option may not be the clinically appropriate drug for that particular person?

Rosemary Maxwell (15:24):

Yeah, and I would absolutely push back if the lower cost drug is not going to be appropriate. Sometimes, you know, a plan will cover a certain drug that's an alternative to the drug that's prescribed by your doctor, and you try the alternative drug, and it, it's fine. It's not a big deal. And it's not a kind of drug where there are, there could be problems right away if you don't get just the right drug. But then other times, there are going to be drugs where it's very important to get the exact drug prescribed by your doctor right away, and there could be clinical health problems caused by a delay in getting the right drug. So those are the times when I think it's really important for the doctor and the patient and the patient's family to push back as soon as they can.

Meryl Comer (16:16):

Monique, you mentioned it earlier, but why is it important for families to understand the difference between Part B and Part D when they're considering Alzheimer's treatment options? Because they're quite different.

Monique Nolan (16:31):

Part B really has a limited coverage, benefit for drugs, but one significant development in the last several years were certain monoclonal antibody drugs that, target, Alzheimer's disease and help with, improving the symptoms and delaying the progression of the disease. , This is something that is currently covered under Medicare Part B, and there are specific definitions that we don't need to get into in, in terms of the statute that sort of dictates what falls under what part. This was a reflection of a national coverage policy that the agency adopted. It's a bit controversial because CMS limited coverage for these new innovative therapies. Patients can have access to these products to the extent they are, registered. CMS wants to continue to develop evidence and information about, coverage of these, products. But it's an example where you may have various, pharmaceutical interventions related to treatment of Alzheimer's or, preventing progression of the disease, and it may be covered under different parts of Medicare.

Monique Nolan (17:42):

And so you wouldn't be thinking about these products as you look at plans, in the upcoming open, open roll, open enrollment season.

Meryl Comer (17:50):

So managing medications for depression, sleep, anxiety, agitation, hallucinations, or psychosis, they fall under Part D, is that correct?

Monique Nolan (18:02):

The limited scope of coverage under Part B really pertains to whether the drug can be self-man - self-administered by the patient the majority of the time. Part B is really limited to drugs that are, for example, infusions or something that a physician or another provider would furnish for and administer for the patient. Whereas Part D, it's really all self-administered products, with the exception under Part B, there are a few categories, like some cancer treatments that are covered, but it's a very limited benefit with respect to those types of, those types of products.

Rosemary Maxwell (18:40):

If I could just jump on, in on that for a second, Meryl. I, it's not the therapeutic class generally that determines whether the drug is Part B covered or Part D covered. It's just the type of drug. If it's a drug that is not usually self-administered, it's probably going to be covered by Medicare Part B. But, so you can have drugs, like, that treat the same disease, and some of them are Part B drugs, others are Part D drugs.

Meryl Comer (19:10):

Rosemary, Monique talked about the Medicare prescription payment plan that some people call smoothing. Is there anything you want to add to that? , You know, it's voluntary. All Part D plans, as I understand it, must offer it, and can be useful to someone with large costs early in a calendar year. But again, it doesn't reduce total costs, right?

Rosemary Maxwell (19:37):

It absolutely does not reduce total costs. Every Part D plan has to offer this smoothing option, and it won't, you know, you've gotta sign up for it. It's not an automatic thing. And it, you know, if you have very high upfront costs, like, you could have a $2,000, a prescription with $2,000 out-of-pocket cost as your first prescription of the year. It'll be, it could help you a lot to have that smoothed out over the course of the year instead of paying for it upfront. And if you elect that smoothie option, you'll get a bill every month from your Part D plan instead of paying money at the pharmacy when you get your drugs.

Meryl Comer (20:20):

So it's accurate to say this program helps with cashflow, but it is not a discount program.

Rosemary Maxwell (20:25):

That's exactly right.

Meryl Comer (20:27):

Okay, just trying to get it right.

Rosemary Maxwell (20:31):

Yes. No, that is exactly the right distinction to make.

Meryl Comer (20:35):

Monique, who is most likely to benefit and who may be better served by pursuing something called extra help? It's the Part D low income subsidy or another financial assistance program.

Monique Nolan (20:50):

Yeah. So there are specific requirements under Part D that determines eligibility for enrollees for LIS or low-income subsidy. , And part and parcel with that is sort of extra help. And that's, what we alluded to before with respect to the smoothing process. It may not be something that's beneficial to an enrollee if they have low-income subsidy.

Meryl Comer (21:14):

Should a person avoid assuming they're not eligible based on a rough estimate of their income?

Monique Nolan (21:21):

To me, the devil is in the details. I wouldn't make assumptions. There are specific criteria, and I do think that's where medicare.gov can be a very helpful, useful resources, for enrollees to identify what they are and aren't eligible for.

Meryl Comer (21:40):

Monique, let me give you a scenario. If a medication is denied or unaffordable, what is the sequence of action? Who should a caregiver call first? The plan, the pharmacy, the prescriber's office, a SHIP counselor, all of the above? I mean, this is where it gets messy and tiresome. <Laugh>

Monique Nolan (22:01):

I think a primary role is the, is the provider in terms of, responding to the plan and, and that type of denial.

Meryl Comer (22:08):

My final question to you both is, what is the one thing you want every Medicare beneficiary and every family to do before the next prescription is filled?

Rosemary Maxwell (22:19):

Make sure that you look at your Part D options. We just entered into the open enrollment period for 2027, so it's time to pick a plan for 2027. You don't have to pick a plan if you're already enrolled in one. You'll be enrolled automatically in your plan for the following year. But you might wan to pick a new plan. There might be another plan that's better. Or if you're a new Medicare beneficiary, then you would not get Part D benefits unless you sign up for a Medicare Part D plan.

Meryl Comer (22:56):

Monique, what's your advice?

Monique Nolan (22:58):

As Rosemary said, if you don't, do your homework, you don't evaluate these types of plans, you will just roll over into the one that you had, and there are changes from year to year, and it may not suit you in a given year. So again, I think carefully assessing your options and working with your providers, with respect to the various products that you're on is really the best way to go to ensure that you're getting, the most you can from your coverage under Part D.

Rosemary Maxwell (23:26):

You almost certainly want to pick a Medicare Part D plan because it's voluntary, but if you don't enroll in Part D, then you're going to face late enrollment penalties in future years if you want to enroll then. So picking a Part D plan is really important.

Meryl Comer (23:44):

Our guests, Rosemary Maxwell and Monique Nolan, both specialists at the DC offices of Arnold & Porter for helping us make sense of a system that's too often complicated when families are least able to absorb more complexity. To our listeners, when it comes to prescription drugs, please don't wait until the pharmacy counter becomes a crisis to ask the questions that can protect health, safety, and financial security. For official Medicare information, visit medicare.gov or call 1-800-MEDICARE. That's it for this edition. Please share this episode with a parent, a friend, a caregiver, or anyone trying to navigate the price of staying well. I'm Meryl Comer. Thank you for brainstorming with us. 

Here's some exciting news to share. BrainGuide by UsAgainstAlzheimer's is highly rated on Everyday Health's top seven list as one of the best Alzheimer's and dementia caregiver support organizations of 2026. We encourage you to check out the free tool today.

Meryl Comer (25:04):

Visit mybrainguide.org.

Close (25:07):

Support for BrainStorm by UsAgainstAlzheimer's comes from Lundbeck US. Lundbeck is dedicated to advancing brain health and transforming lives through focused innovation in neuroscience. Subscribe to Brainstorm through your favorite podcast platform and join us for new episodes on the first and third Tuesday of every month.