Will specialty medications still be covered by Medicare Part D in 2025?

The average annual cost of specialty drugs can exceed $10,000, creating a significant financial burden for many patients.

If you're one of the millions of Americans relying on specialty medications to manage serious health conditions like cancer, rheumatoid arthritis, or multiple sclerosis, you're likely facing high drug costs. The good news is certain classes of drugs are still covered but there’s a chance that some may not be.

Why you should pay attention to your ANOC

Every fall, you'll receive what's known as the Annual Notice of Change (ANOC) from your Medicare Part D plan. It outlines

• Any changes to your plan's benefits, premiums, or costs for the upcoming year.
• Updates to the formulary, including new prior authorization (PA) requirements, tier changes, or drug removals.

Plans must send these notices by September 30th by mail or email, giving you time to review changes before the Open Enrollment Period which begins on October 15th and ends on December 7th.

You can call your plan to request a copy or clarification on the changes

Your plan can't just send this notice and consider their job done. They're required to ensure you actually receive and can understand the information. This means:

• If you're visually impaired, you can request large print or braille formats
• If English isn't your primary language, you're entitled to translation services
• If you've opted for electronic communications, they must confirm your receipt

What are protected classes?

Medicare Part D includes six "protected classes" of drugs. These are categories of medications considered essential for treating serious health conditions.

These drugs cannot be removed from the formulary unless they are deemed unsafe or withdrawn from the market.

Plans are required to cover all or almost all drugs within these protected classes. This means you can generally count on continued access to your specialty medications, even with the changes in 2025.

What does the $2,000 cap mean for specialty drugs?

The new $2,000 out-of-pocket cap will significantly benefit people taking high-cost specialty medications. Here's how it works:

• Before the cap: You'll pay your plan's cost-sharing (copays or coinsurance) for your specialty drugs. This can still be a significant amount (close to $8,000), especially if your medications are in a higher tier (like Tier 5).
• After the cap: Once you reach $2,000 in out-of-pocket spending for covered drugs, you'll pay $0 for the rest of the year, including your specialty medications.

This means you'll have a limit on your out-of-pocket expenses, even if your medications cost tens of thousands of dollars per year.

Formulary changes and tiering

While specialty drugs are protected, it's important to remember that plans can still make changes to their formularies. This means:

• Tier changes: Your medication might move to a different tier, affecting your cost-sharing before you reach the cap.
• Prior authorization: Some medications might require prior authorization from your plan before they're covered.

Review your plan's formulary during open enrollment to make sure your specialty drugs are still covered and understand any changes in cost-sharing or restrictions.

What happens when a drug is removed from your plan's formulary?

It can be alarming to discover that a medication you rely on is no longer covered by your Medicare Part D plan. You have options and rights to ensure continued access to your treatment.

Why your plan may remove a brand-name drug from the formulary

• A generic version of your medication becomes available.
• It is considered less cost-effective compared to other treatments.
• There are safety concerns.
• Very few people use a particular drug.

Your right to transition fills

Perhaps one of the most underutilized yet crucial protections is your right to transition fills.

Let's say you join a new plan in January and discover your blood pressure medication isn't covered. Instead of panicking, you can get your medication filled under transition fill rights while you and your doctor either find an alternative or file for an exception.

Here's how they really work:

For new plan members: You're entitled to at least a 30-day supply of your current medications during your first 90 days in the plan, even if the drug isn't on the formulary. This isn't just a one-time fill – you can get multiple fills during this period if needed.

For existing members: If your medication gets dropped from the formulary or new restrictions are added, you're entitled to a transition fill while you either switch medications or request an exception.

For long-term care residents: The rules are even more generous: you're entitled to at least 31 days, and potentially up to 98 days of medication. This extended period recognizes the complexity of changing medications in a long-term care setting.

What to do when your drug is no longer covered

• Request a transition fill. This way, you’ll have a temporary supply (usually 30 days) of your medication while you explore other options.
• Switch medications. Talk to your doctor about alternatives.
• File a formulary exception or appeal with your plan. Work with your doctor to make a strong case.
• Switch plans: Find a plan that covers your medication during open enrollment.
• Apply for assistance programs: Several manufacturers and charitable foundations offer prescription assistance.

You can check if you qualify for assistance and apply on your own, or request enrollment assistance from our team at GetCopayHelp.