Decoding the 2025 Medicare Shifts: Key Insights for Pharma Market Access with Parker Edman
With the recent release of the 2025 Medicare plan enrollment data, pharma manufacturers must address significant shifts in the Part D prescription drug plan market, that could impact market access, formulary positioning, and patient affordability. We spoke with Parker Edman about the trends, challenges, and what manufacturers should prioritize to stay ahead.
Q: What makes this enrollment data release particularly significant for pharma manufacturers?
Parker Edman: 2025 is the first full implementation year of the Part D Redesign under the Inflation Reduction Act, making this a pivotal year for Medicare plan structures and beneficiary choices.
One major trend we’re seeing is a reduction in the number of available plans – dropping from approximately 4,200 in 2024 to about 3,700 in 2025. That’s an 11% decrease, and a big percentage of that comes from standalone Prescription Drug Plans (PDPs) disappearing.
Fewer plans mean fewer choices for patients which translates to changes in coverage, cost-sharing, and reimbursement. Pharma manufacturers need to be thinking ahead – how will these changes affect formulary access, utilization management and patient affordability?
Q: At first glance, what major trends or shifts in Part D enrollment have you noticed?
PE: There are two major enrollment trends I am observing in the 2025 Part D market.
First, we have seen a stall in the decline of non-employer group standalone Prescription Drug Plans (PDP) plans. Since 2018, there has been a steady decline in the enrollment of standalone PDP plans. When the IRA was passed, many people predicted this trend would accelerate as PDP premiums increased; however, the IRA cap on annual increases to the Part D base beneficiary premium at 6% each year and a last-minute demonstration program from the Biden administration to subsidize standalone PDP premiums in 2025, stalled premium increases and likely stalled the decline by making PDPs more competitive with MA-PDs.
Another factor that potentially stalled this trend – which I believe went unnoticed as individuals hyper-focused on the impacts of the IRA – were Medicare program rate cuts and increased patient utilization trends that decreased Medicare Advantage patient plan choice for the 2025 program year in certain regions. Manufacturers should continue to closely monitor enrollment shifts and formulary coverage across both plan types.
Second, we are seeing early signs that there were significant shifts for low-income subsidy (LIS) program enrollees. For example, Aetna’s SilverScript Choice plan – the most popular benchmark plan in the past – removed its status as a benchmark plan from 14 PDP regions in 2025. We are seeing a sizable increase in enrollment among benchmark plan competitors to SilverScript Choice – like Wellcare Classic. We can confirm these shifts once LIS specific enrollment data is released later in the year.
For manufacturers, this means vulnerable patient populations will likely see changes in formularies and coverage.
Q: How do these changes impact pharma manufacturers’ market access and reimbursement strategies?
PE: When patients switch plans, their drug coverage can change overnight. Tier placement and utilization management requirements may be different. Manufacturers must be proactive in identifying which Medicare plans are growing, which are losing enrollment, and how their drug coverage is shifting.
With fewer standalone PDP options, MA-PD formulary access becomes even more important. Manufacturers should be closely tracking these plans, assessing any new access barriers, and adjusting their payer engagement strategies accordingly.
Q: What potential challenges could arise for manufacturers in terms of formulary access and utilization management?
PE: Anytime patients transition to new plans, there’s a risk of treatment disruption. Prior authorizations may need to be re-submitted, step therapy may reset or need to be redocumented, and some patients may even abandon therapy if they hit roadblocks.
This is when field and hub teams can help. Proactively identifying which plans are gaining enrollment and what their utilization management requirements look like will be critical. The more manufacturers can prepare, the better they can support continuity of care.
Q: How should pharma companies rethink patient affordability programs in light of potential enrollment shifts?
PE: It’s a major issue. Many LIS patients rely on government subsidized cost sharing assistance to afford their medications – which is already stressful enough as it is. You then add in changing plans and the affordability and access problems can multiply quickly.
Beyond that, we’re continuing to see a shift from copay to coinsurance in Part D. More patients will be paying a percentage of their drug costs rather than a fixed amount, which usually means higher out-of-pocket costs–especially for high-cost therapies.
While relief for patients will come with the $2000 out-of-pocket (OOP) max, patients taking products on, say, a preferred brand tier within their plan may still have a moment of “sticker shock.” This is a moment patients and providers need education, resources, and reassurance to ensure abandonment doesn’t occur. Manufacturers will need to reassess their patient affordability and hub programs to ensure they’re aligned with these changes.
Q: What role does data analytics play in helping manufacturers interpret and act on these enrollment changes?
PE: The key is having the right data at the right time. A formulary databook highlighting key coverage dynamics can help manufacturers track market shifts and adjust strategies accordingly.
For example, if we see a major enrollment spike in certain MA-PD plans, manufacturers need to analyze how those plans handle formulary access, cost-sharing, and utilization management. That kind of insight helps teams refine contracting strategies, optimize patient assistance programs, and align field teams to support patient access.
Q: What are the most important next steps for pharma manufacturers now the enrollment data is released?
PE: There’s a clear three-step approach:
- Validate the data. Are we seeing the expected enrollment shifts? Is PDP enrollment declining? Is MA-PD growth continuing? Which plans gained or lost LIS enrollees?
- Assess the impact. How many patients switched plans? Are there emerging access or reimbursement challenges?
- Develop a response strategy. Which plans are attracting the most patients? Do field teams understand their formulary structures, utilization management hurdles, and cost-sharing requirements?
Taking these steps will help manufacturers align their market access strategy, payer engagement efforts, and patient support programs with the shifting Medicare landscape.
Final Thoughts and Next Steps
Medicare Advantage and Part D enrollment landscape is shifting, and manufacturers must be proactive. The key is staying ahead of these trends-tracking enrollment data, understanding formulary impacts, and engaging with key stakeholders.
Magnolia Market Access offers insights and strategies to help manufacturers navigate these changes confidently.
For a deeper understanding of how these Medicare changes could impact your market access strategy, connect with an expert to explore tailored solutions aligned with your brand’s goals.