Possible Drug Coverage Changes in 2025 for Medicare and Other Insurance Plans

Important Changes to Medicare, Federal, and Private Drug Plans for 2025

Starting January 1, 2025, there will be significant changes to Medicare and other insurance plans' coverage of formulary vs. non-formulary drugs. If you’re unfamiliar, a formulary is the list of medications that your insurance plan covers, often organized by tiers that affect how much you pay. Drugs not on the formulary (non-formulary drugs) are not covered at all, meaning you’ll have to pay the full cost out-of-pocket.

It’s critical for all enrollees to review their prescription coverage to see if their medications have moved to different tiers or are no longer on the formulary. This could include essential high-cost cancer drugs, which may no longer be covered or be covered at a lower rate by some Medicare Advantage, Part D Drug Plans, or other insurance plans.

If your plan no longer covers these medications, you have until December 7th for Medicare and Medicare Advantage—the end of the open enrollment period—to explore other plans. If no plan in your area provides coverage, work with your doctor now to request an exception for "medically necessary" drugs. If covered by federal or private insurance, be aware of your open enrollment period to not miss any deadlines. Being proactive can help you avoid disruptions in your treatment.

How the Changes Affect Blood Cancer Patients

If any cancer treatment drugs are excluded from your specific plan, you’ll be required to pay the full price out-of-pocket. Consider asking for a generic of the drug if possible. Additionally:

• Costs for non-formulary drugs won’t count toward your maximum out-of-pocket (MOOP) limit of $2,000.

• The MOOP cap only applies to prescriptions covered by your plan.

If you’re a blood cancer patient on other drugs (outside of cancer treatment), you should also review your plan for potential coverage changes. Each plan determines its own prescription coverage, so there’s little consistency across plans.

What About Private Insurance Plans?

If you’re on private employer-sponsored insurance, ACA, or COBRA, don’t assume your coverage hasn’t changed for 2025. Private plans are also undergoing substantial shifts, and many people will be affected. Review your options carefully to ensure your medications are still covered. 

What You Can Do Now

Here are steps you can take to prepare for these changes and ensure continued access to your medications:

1. Understand Formulary vs. Non-Formulary Drugs: A formulary is your plan’s list of covered medications. Drugs on the formulary may be divided into tiers, with higher tiers often costing more. Non-formulary drugs are not covered by your insurance plan, meaning you’ll have to pay their full price out-of-pocket. Review your plan to determine which tier your medication falls under or if it’s covered at all. 
2. Review Your Plan Changes: You should have received a Summary of Plan Changes in September. Read it carefully and identify any potential issues with your coverage.
3. Contact Your Insurance Provider: Contact your plan for details about drug coverage changes, including alternatives like generics.
4. Work with Your Doctor: Discuss with your healthcare provider to request prior authorizations or exceptions for "medically necessary" prescriptions.
5. Don’t Wait: Avoid finding out about coverage issues at the pharmacy. Start now to prevent treatment gaps.
6. Ask for an Alternative: If your prescribed drug is not in your Plan formulary, request a generic if possible. Still, check to make sure it is also a Plan formulary-covered drug.

Seek Assistance If Needed

If you’re overwhelmed by these changes, you’re not alone. You can reach out to your State Health Insurance Assistance Program (SHIP) for guidance. Visit www.shiphelp.org to speak with a counselor in your state.

Another helpful resource is CMS.gov, which can help you review your Medicare plan. 

Act Now to Avoid Catastrophic Costs

Failing to act during this enrollment period could have devastating financial consequences, especially if you rely on expensive medications. Remember, this year’s changes are substantial, and your 2024 coverage details will not apply in 2025. Be proactive to secure the best plan for you and your family.

Extra Resources on the Subject:

• 2025 Medicare Open Enrollment Updates 
• 2024-2025 Medicare Drug Cost Changes: Key Updates
• Everything you need to know about Medicare reforms - PAN Foundation