Rising Medicare Part D Premiums Threaten Patient Adherence and Strain Pharmacy Resources

The healthcare landscape for Medicare beneficiaries is undergoing a significant shift, with rising Medicare Part D premiums poised to create new financial and clinical challenges for patients and pharmacists alike. In an interview with Pharmacy Times, Dr. Scott Soefje, a leading oncology pharmacist, discussed the potential implications of these changes, emphasizing that while the full impact remains speculative, the threat to patient adherence and the burden on healthcare systems are very real. These changes are part of the larger unwinding of a federal premium stabilization program, which is reducing its subsidy and allowing for higher premium increases in 2026.

The Looming Threat of Cost-Related Non-Adherence

Dr. Soefje highlighted a fundamental principle of patient adherence: any increase in out-of-pocket costs, even a minor one, can lead patients to stop taking their medications. He cited existing literature that shows even small copay increases, sometimes as little as five or six dollars, can be enough to trigger non-adherence. This is a particularly critical concern for oncology patients who rely on expensive, life-saving oral therapies. When a patient who is responding well to treatment suddenly receives an unexpected bill, the decision to continue or abandon their medication becomes a difficult financial choice that can directly impact their health outcomes.

Increased Burden on Pharmacists and Health Systems

As premiums rise, pharmacists—especially those in oncology—will be faced with difficult professional and ethical dilemmas. Dr. Soefje anticipates that pharmacists will increasingly have to weigh the risks of continuing an effective but high-cost medication against switching a patient to a cheaper, potentially less effective alternative.

Furthermore, pharmacists will be pulled into new administrative responsibilities, particularly for health systems that lack a dedicated infrastructure for financial counseling. This includes helping patients navigate a complex web of manufacturer-sponsored patient assistance and copay programs. Pharmacists, as medication experts, are often the first point of contact for patients with drug-related financial questions, and these changes will significantly increase that burden.

Tighter Formularies and Shifting Access Barriers

The financial pressures on Part D plans are also expected to lead to a tightening of drug formularies. Dr. Soefje predicts that managed care systems and pharmacy benefit managers (PBMs) will increasingly rely on tools like step therapies and tiered formularies to manage costs. This will likely leave patients confused and frustrated, as they may not understand why they cannot access a specific medication recommended by their doctor.

While Dr. Soefje notes that this could potentially lead to a more streamlined formulary with a focus on a few “workhorse” therapies, the immediate impact will be on patient access. He believes this will force pharmacists to become even more skilled at intervening to address these access barriers and to counsel patients and physicians on formulary changes.

The Imperative for Enhanced Benefit Counseling

The complexity of Medicare plans—which includes options like Medicare Advantage, managed care, and dual-eligible programs—has long been a source of confusion for patients. Dr. Soefje pointed out that with rising premiums and shifting plan benefits, the need for expert benefit counseling is more urgent than ever, especially for older adults on fixed incomes.

While benefit counseling has traditionally been handled by financial counselors, Dr. Soefje believes pharmacists must become more knowledgeable about the intricacies of Medicare and Medicaid reimbursement. This will be essential for answering patient questions during Open Enrollment and helping them make informed decisions that do not compromise their ability to afford and adhere to their prescribed medications. The changes represent a “big lift” for the pharmacy profession, requiring a concerted effort to increase knowledge and expertise to navigate a new and challenging era of healthcare.