Review the UnitedHealthcare Medicare Part D drug cost and formulary changes

Beginning Jan. 1, 2025, the Inflation Reduction Act (IRA) will introduce additional changes to prescription drug costs and payment flexibility for UnitedHealthcare® Medicare Advantage members. These changes include:

• Lower maximum out-of-pocket prescription drug costs
• Removal of coverage gap
• Introduction of a new Medicare Prescription Payment Plan

You can learn more about these changes on our IRA page.

Prescription drug cost changes

Due to regulatory changes impacting the Medicare Advantage and Part D program, most Medicare Advantage members will experience the following benefit changes in 2025:

• Part D prescriptions on tiers 3, 4 and 5 will have new or increased deductibles
• Part D prescriptions on tier 4 will be limited to a 30-day supply instead of a 3-month supply starting in 2025

These changes will not affect employer groups with Medicare Advantage Part D plans.

We understand stable costs for the most-used prescriptions are important to our members. That’s why nearly all UnitedHealthcare Medicare Advantage members will continue to not have Part D deductibles for tier 1 and 2 prescriptions and $0 copays for tier 1 prescriptions, as well as stable copays for tier 2 prescriptions. Members who use Optum Home Delivery Pharmacy will continue to have access to $0 tier 1 and tier 2 medications.

GLP-1 agonist prior authorization requirement update

Beginning Jan. 1, access to covered GLP-1 agonist therapy will require submission of medical records to confirm the diagnosis of type 2 diabetes.

This means, if covered GLP-1 therapy is required starting on Jan. 1, 2025, you’ll need to submit a type 2 diabetes ICD-10 claim to UnitedHealthcare or submit prior authorization to OptumRx with additional documentation to confirm a type 2 diabetes diagnosis. If you have a GLP-1 therapy claim with a date of service prior to Jan. 1, 2025, this requirement applies as well.

Select 2025 formulary changes that affect UnitedHealthcare Medicare Advantage Part D members

We’ve also updated our Individual UnitedHealthcare Medicare Advantage and Prescription Drug Plan formularies, including those for non-SNPs, D-SNPs, C-SNPs and standalone Prescription Drug Plans (Preferred and Saver), all taking effect on Jan. 1, 2025.

The following table outlines the preferred covered alternatives that may be suitable options for your affected patients. These preferred covered alternatives may require prior authorizations, depending on the drug’s guidelines.

There may be additional formulary changes that affect your Individual Medicare Advantage and/or Prescription Drug Plan members.

Select 2025 UnitedHealthcare Medicare Advantage and Prescription Drug Plan formulary removals

*Alternative coverage may vary by formulary; please use PreCheck MyScript or a plan website to confirm covered alternatives.

You can view covered alternatives and other formulary coverage by using PreCheck MyScript through most electronic medical records’ real-time benefit check functionality or the UnitedHealthcare Provider Portal. 

If you don’t have access to PreCheck MyScript, please review prescription drug formulary information at:

• AARP Medicare plans 
• UnitedHealthcare Medicare options
• UnitedHealthcare drug list and pharmacy updates

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