By Christian Regalado
This year has been more confusing than most. Medicare has always been complex, with a variety of options and terminology that most people just don’t understand. That is why the services of an independent broker are helpful, especially when they are at no cost to the client. Having a professional you can rely on to help navigate these complexities is similar to having an accountant for help filing taxes or a lawyer to help draw a will. The only difference is that your independent broker won’t send you a bill for their services. We are commission-based and work with multiple carriers in the area. I focus on contracting with established companies that have the most competitive products. The carrier that best fits a client’s needs is dependent upon personal situations. My job is to navigate the sea of options based on individual needs and preferences.
This year is unusual in a few respects. The good news was that the maximum out-of-pocket cost for prescription drugs dropped from $8000 to $2000 per year. For those on expensive drugs, this was terrific. The downside was that the insurance companies made up for this loss in revenue in several ways. The obvious was an increase in premiums on most prescription drug plans. For those on Medicare Advantage plans, certain benefits were either reduced or eliminated with increased copays. There were also changes in the insurance carrier’s formularies which is the list of drugs that are covered.
These are some of the stories that I heard from clients: An expensive drug that was covered in 2024 was no longer covered by that carrier in 2025. I had to find an insurance company whose drug formulary did cover that drug. If they had stayed on their old plan, the drug would not be covered, and it wouldn’t count towards the $2000 out of pocket maximum. That could have been a very expensive mistake.
I also had a client with a similar situation that had an expensive drug that was no longer covered and we could not find any other plan that covered the drug. Luckily, we were able to request a formulary exception and the company honored it. However, starting next year, they may have to consult with their doctor to find a similar drug that we can find in a PDP plan that will cover the drug.
Another client had a generous dental benefit on their Advantage plan that was reduced in 2025. Again, I had to search for a new carrier with a plan that offered better dental benefits. Other clients that had their dental benefit reduced opted to choose a different PPO plan that had a great network and a generous part B give-back benefit to make up for the difference in their dental coverage reduction.
One big reason for changes in 2025 was that a major carrier had a change of network. Doctors in their plan for 2024 could no longer be covered in 2025. Some folks kept their plan and changed doctors while others changed Advantage plans so that they could keep their current doctors. This has been a big issue that I was able to help multiple clients resolve just in time before the Open Enrollment Period ended on March 31. There were also changes in dental networks and dentists that took a particular plan in 2024 and are no longer accepting it in 2025.
This year also presented a stark contrast of Advantage plans vs Supplement plans. Recent press articles on Advantage plans have been mostly negative. However, nationally, more folks are enrolling in Advantage plans primarily due to no or low premiums and the extra benefits such as dental, vision and hearing. Locally, I see more people enrolling in Supplement plans but most still enroll in an Advantage plan.
If you are looking at enrolling in a Supplement plan, know why it may make more sense for you. One person wanted to enroll with the same carrier she had in her group plan. She thought that this would help to make sure her doctors were in network. Supplement plans don’t have networks. They are accepted by any doctor or hospital that accepts original Medicare. That is one of the positive reasons to enroll in a Supplement plan. She may have enrolled in a plan with a higher premium for the wrong reason.
Everyone’s story is different. Let us hear your story and help you select the right plan for you. Should you have any questions or need help, please contact me. My services are no cost to you and I am always happy to help a neighbor. Reach out anytime! Email Christian@evergreenhealthins.com or call (850) 687 7606.
Author: Sowal Editor
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