IRA Fallout: What 2025 Medicare Shifts Mean for Patient Access and Market Strategy

Today’s guest post comes from Scott Hughes, Vice President of Strategy of CareMetx.

In this latest analysis from CareMetx, Scott explores how the Inflation Reduction Act (IRA) is reshaping Medicare patients’ access to critical medications across three high-impact therapeutic areas: immunology, oncology, and endocrinology. Drawing on fresh 2025 plan data, he highlights the emerging barriers faced by patients, the shifting demands on providers, and the strategic implications for drug manufacturers.

To learn more, download CareMetx’s complete analysis: The IRA Disruption Report: A Strategic Look at Patient Access Changes.
 
Read on for Scott’s insights.

IRA Fallout: What 2025 Medicare Shifts Mean for Patient Access and Market Strategy
By: Scott Hughes, Vice President of Strategy, CareMetx

The Inflation Reduction Act (IRA) promised cost relief for patients—and in many ways, it’s delivering. A $2,000 out-of-pocket cap, $35 insulin, $0 vaccines, and expanded eligibility for low-income subsidies are all major wins. But those gains are triggering ripple effects throughout the healthcare landscape, especially for drug manufacturers.

To fund these patient-friendly benefits, Medicare plans have made tough trade-offs. Many have slashed formularies, increased cost sharing, or tightened prior authorization (PA) requirements. The result? Millions of beneficiaries are being forced to switch therapies, appeal denials, or seek entirely new coverage—meaning manufacturers are left to navigate an increasingly complex access landscape.

To understand the full impact, CareMetx conducted a deep analysis of 2025 Medicare Advantage (MAPD) and Part D (PDP) plans, tracking the shifts in benefit design, formulary access, and utilization management across three key therapeutic areas. That research is captured in our latest report, which offers a data-driven view into how the IRA is reshaping the market—and what it means for patient access strategy moving forward.

Consider three therapeutic areas where shifts in coverage and utilization management are already taking shape: immunology, oncology, and endocrinology. A closer look at some of the most prescribed brands within these categories reveals how the IRA’s ripple effects are playing out across the access landscape.

Immunology: Coverage Gaps and Rising Hurdles

High-cost immunology drugs were early targets for plan cuts.

• One therapy lost coverage for over 15 million beneficiaries under Part D alone
• Another was dropped by plans covering 8.5 million MAPD lives
• Prior authorization requirements spiked—one drug saw 3 million new beneficiaries suddenly needing approval
• Out-of-pocket costs climbed for 200,000 to 500,000 beneficiaries across multiple therapies

Bottom line—millions of current and potential immunology patients are facing new hurdles to access medications that were previously more readily available.

Oncology: Increased Barriers to Access

Even essential cancer therapies are being affected by shifting access decisions.

• A top oncology drug lost coverage for 200,000 beneficiaries
• PAs surged—one therapy now requires approval for 561,000 additional beneficiaries under MAPD
• Cost-sharing increased for nearly 3 million beneficiaries, despite the IRA’s intent to reduce financial burden

In a therapeutic area where timely, uninterrupted access can be critical, new obstacles are putting added pressure on patients and providers alike.

Endocrinology: Escalating Costs and Coverage Losses

Even common therapies for conditions like diabetes saw major shifts.

• One drug was removed from plans covering nearly 6 million beneficiaries
• Another now requires prior auth for 6 million+ MAPD beneficiaries
• Cost-sharing increased across the board—impacting more than 1 million lives across just 4 common brands reviewed in our assessment

In short, chronic disease management just got more complicated and costly for millions of Americans.

What This Means for Manufacturers

The bottom line? IRA-driven changes are reshaping access, with varying impacts across different therapeutic areas. Manufacturers will need to account for more variability, more complexity, and more plan-by-plan nuances.

This snapshot highlights early trends—but the full picture is more complex. To view more comprehensive data and get a deeper understanding of where beneficiaries in these therapeutic areas may be affected, download the full CareMetx analysis: The IRA Disruption Report: A Strategic Look at Patient Access Changes.

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