Medicare coverage shifts
Reporting shows some Medicare Part D plans provide restrictive coverage for certain rheumatoid‑arthritis drugs, and major insurers have scaled back some Medicare Advantage offerings for 2026. Those coverage changes are being flagged as new friction points for retirees navigating drug costs and plan choices. (healio.com, wlsn.co)
Some Medicare drug plans are covering key rheumatoid arthritis medicines unevenly in 2026, while Medicare Advantage shoppers are also seeing fewer plan choices. (healio.com) A new study in *Arthritis & Rheumatology* reviewed Medicare Part D formularies from 2022 through 2026 and found many plans excluded at least one major class of self-administered rheumatoid arthritis drugs. The researchers examined tumor necrosis factor inhibitors, T-cell co-stimulatory modulators, interleukin-6 inhibitors, and Janus kinase inhibitors. (pubmed.ncbi.nlm.nih.gov) The gaps were widest in stand-alone Part D drug plans: 10.4% covered at least one drug from all major classes, versus 37.6% of Medicare Advantage drug plans. The class most often left out was the T-cell co-stimulation category, which includes abatacept. (medpagetoday.com) Youngmin Kwon of Vanderbilt University Medical Center said plans have been narrowing formularies in recent years to strengthen price negotiations with drugmakers. He said that can complicate rheumatoid arthritis care, where patients often need to try more than one therapy over time. (healio.com) At the same time, Medicare Advantage plan menus are shrinking for 2026 after several years of expansion. Kaiser Family Foundation found the average beneficiary will have 32 Medicare Advantage plans with drug coverage in 2026, down from 34 in 2025. (kff.org) Across all individual Medicare Advantage plans, including those without drug coverage, the average choice fell to 39 plans in 2026 from 42 in 2025. Kaiser Family Foundation counted 3,373 individual Medicare Advantage plans nationwide for 2026, a 9% drop from 2025. (kff.org) The pullback is not uniform. Kaiser Family Foundation said 35 states, the District of Columbia, and Puerto Rico have fewer Medicare Advantage prescription drug plans on average in 2026 than in 2025, while six states have more and eight are unchanged. (kff.org) Plan terminations are also hitting more people this year. Kaiser Family Foundation said 2.6 million beneficiaries were enrolled in Medicare Advantage plans that terminated coverage at the end of 2025, though 98.9% of those beneficiaries still had at least one Medicare Advantage prescription drug plan available for 2026. (kff.org) The Centers for Medicare & Medicaid Services finalized 2026 Medicare Advantage and Part D policy changes on April 4, 2025, and said the rule covers prescription drug coverage, the Medicare Prescription Payment Plan, and other program rules. Separate 2026 Part D instructions said the benefit structure is being updated on January 1, 2026, to reflect Inflation Reduction Act changes. (cms.gov, cms.gov) For retirees comparing coverage this year, the practical question is no longer just premium size. It is whether a plan still exists in their county and whether its drug list still includes the medicine their specialist may want to use next. (kff.org, healio.com)
