Yes, drug costs are rising for most Medicare Advantage plans in 2025
Most people with Medicare Advantage will pay more for prescription drugs in 2025 than they did in 2024. The increases vary by plan and by drug, but the trend is widespread. Some plans are raising copays for brand-name drugs, increasing deductibles, or moving drugs to higher cost tiers where you pay a larger share of the price.
The reasons are complex: pharmaceutical manufacturers keep raising list prices, fewer generic alternatives exist for newer drugs, and insurance companies adjust their cost-sharing to manage their own expenses. What matters to you is understanding whether your specific plan changed, what those changes mean for the drugs you take, and what your options are if the new costs are too high.
Key Takeaways
- Your plan's drug formulary — the list of covered drugs and their costs — changes every year, and 2025 brings increases for most people.
- You can see your plan's 2025 drug costs now by using the Medicare Plan Finder tool on Medicare.gov or calling your plan directly.
- If your drugs moved to a higher cost tier or your copay increased, you have until December 31, 2025, to switch to a different Medicare Advantage plan.
- Some drugs that were covered in 2024 may no longer be covered in 2025, but your doctor can request an exception through a process called a formulary exception.
- The Part D coverage gap (donut hole) no longer exists for Medicare Advantage members, but your out-of-pocket costs still add up and vary by plan.
How to learn about your specific drugs cost more in 2025
The fastest way is to use the Medicare Plan Finder at Medicare.gov. Enter your zip code, select your current plan, and look at the "Prescription Drugs" section. The tool shows you the copay or coinsurance for each drug you take under that plan for 2025. You can also compare what the same drugs would cost under other Medicare Advantage plans in your area.
If you prefer to talk to someone, call your plan's customer service number — it is on your current insurance card. Tell them the name and dose of each drug you take, and ask what the copay will be in 2025. Write down the answer. If the cost went up, ask whether the drug moved to a different tier or whether the plan changed its copay structure across the board.
Do this now, before 2025 begins. Waiting until January means you may pay the higher cost for a month or two before you realize you could have switched plans.
What happens if a drug you need is no longer covered
Medicare Advantage plans can remove drugs from their formulary or restrict how you can use them. If your doctor prescribed a drug that is no longer covered in 2025, you have options. The first is to ask your doctor whether a similar drug on the 2025 formulary would work for you. Many conditions have multiple treatment options, and your doctor may be willing to switch you to something the plan does cover.
If your doctor believes the drug on the formulary is not right for you, they can submit a formulary exception request. This is a formal request asking the plan to cover the drug anyway. The plan has 72 hours to respond. If they say no, your doctor can appeal. This process takes longer than straightforward switching drugs, but it is an option if the drug is truly necessary for your condition.
You can also switch to a different Medicare Advantage plan that does cover the drug, or switch to Original Medicare with a separate Part D prescription drug plan. Both changes are allowed during the Annual Enrollment Period (October 15 to December 7 each year) or if you have a may have access to life event.
Understanding drug cost tiers and how they work in 2025
Medicare Advantage plans organize drugs into tiers, usually four or five levels. Tier 1 drugs (generics) have the lowest copay. Tier 2 (preferred brand-name drugs) costs more. Tier 3 (non-preferred brand-name drugs) costs even more. Tier 4 or 5 (specialty drugs) have the highest copays, sometimes 25% to 33% of the drug's cost.
In 2025, many plans are moving drugs up a tier or creating new restrictions. For example, a drug that was Tier 2 in 2024 might be Tier 3 in 2025, meaning your copay doubles. Some plans now require you to try a cheaper drug first before they will cover the more expensive one — this is called step therapy. Others require prior authorization, meaning your doctor has to call the plan and get permission before you can fill the prescription.
When you check your 2025 costs, look not just at the copay amount but also at any restrictions listed next to the drug. If it says "step therapy required" or "prior authorization required," that means there is an extra step before you can get the drug filled.
When you can switch plans because of drug cost increases
You can change Medicare Advantage plans during the Annual Enrollment Period, which runs from October 15 to December 7 each year. Changes take effect January 1. You can also switch during the Medicare Advantage Open Enrollment Period, which runs January 1 to March 31 each year, but only if you are already in a Medicare Advantage plan.
If you have a may have access to life event — such as moving to a new state, losing your current coverage, or having a major change in your health — you may be able to switch outside these windows. Losing access to a drug you need because of a formulary change does not automatically count as a may have access to event, but it is worth asking your plan or calling Medicare at 1-800-MEDICARE to find out whether your situation qualifies.
If you are considering switching, use the Medicare Plan Finder to compare your current plan's 2025 drug costs with other plans available in your area. Look at the total out-of-pocket cost for all your drugs, not just one. Some plans have lower copays but higher deductibles, or vice versa.
What to do if you cannot afford your 2025 drug costs
If your copays are too high, start by talking to your doctor. Ask whether a generic version of your drug exists, or whether a different drug in the same class would work. Generic drugs almost always cost less, and your doctor may be open to switching if it means you can actually afford to take the medication.
Check whether the drug manufacturer offers a patient information program. Many pharmaceutical companies provide free or reduced-cost drugs to people who cannot afford them. Your doctor's office or the manufacturer's website can tell you how the process works. These programs are separate from Medicare and do not count toward your out-of-pocket maximum.
You may also be able to get help through a nonprofit organization that assists with prescription drug costs. Organizations like NeedyMeds, Patient Advocate Foundation, and Partnership for Prescription information maintain databases of programs. Your local Area Agency on Aging can also point you toward resources in your community.
How the 2025 out-of-pocket maximum affects your drug costs
Every Medicare Advantage plan has an out-of-pocket maximum — a cap on how much you pay in a year for covered services, including drugs. In 2025, this maximum varies by plan but cannot exceed $8,850 for in-network care. Once you reach that amount, the plan pays 100% of your covered costs for the rest of the year.
The out-of-pocket maximum includes copays and coinsurance for drugs, doctor visits, hospital stays, and other covered services. It does not include your monthly premium. If you take expensive drugs, reaching the out-of-pocket maximum partway through the year means your drug costs drop to zero for the remaining months — but you still have to pay your monthly premium.
When comparing plans, look at both the copay amounts and the out-of-pocket maximum. A plan with higher copays but a lower out-of-pocket maximum might cost you less overall if you take multiple expensive drugs.
Frequently Asked Questions
Can my Medicare Advantage plan change my drug copay in the middle of the year?
No. The copays and formulary you see for 2025 are locked in for the entire year. Your plan cannot raise copays or move drugs to higher tiers between January and December 2025. However, if a drug is recalled or becomes unavailable, the plan may remove it from the formulary.
What is the difference between a copay and coinsurance for drugs?
A copay is a fixed dollar amount you pay each time you fill a prescription — for example, $10 for a generic drug. Coinsurance is a percentage of the drug's cost that you pay — for example, 20% of the price. Specialty drugs often use coinsurance rather than copays because the drugs are very expensive.
If I switch Medicare Advantage plans in December, when does my new coverage start?
If you switch during the Annual Enrollment Period (October 15 to December 7), your new plan's coverage begins January 1. Your old plan ends December 31. Make sure you have enough of your current medications on hand to last through the end of December, because your old plan will not fill prescriptions after December 31.
Do I have to pay the full copay if my drug costs less than the copay amount?
No. You pay whichever is lower: the copay or the actual cost of the drug. If your copay is $50 but the drug costs $30, you pay $30. This is called "copay accumulation" and it counts toward your out-of-pocket maximum.
What happens if my doctor prescribes a brand-name drug but a generic version exists?
Your plan may require you to use the generic version first before covering the brand-name drug. This is step therapy. If the generic does not work for you, your doctor can request an exception. The plan has 72 hours to decide. If they deny it, your doctor can appeal.