Time-Sensitive Information for People with Medicare Who Take Revlimid 

People across the U.S. are experiencing significant difficulty finding Medicare Part D plans that include Revlimid on their 2025 formularies. The formulary is the list of drugs that are covered by a plan. 

This may be a problem not only if you’re searching for a new plan, but also if you’ve been planning to keep your current plan for next year.  

Many Part D plans that include Revlimid on their 2024 formularies, do not for 2025. 

If you are in this situation, there are steps you can take now to try and continue to have Revlimid covered by your Part D plan.  

Some of these steps are time-sensitive, especially as Open Enrollment ends on December 7! 

Step 1: Check if your 2025 Part D plan includes Revlimid on its formulary.  

You can do this by using Medicare’s Plan Finder tool. Make sure you’re looking at coverage for 2025, as Plan Finder has information for both 2024 and 2025. 

Step 2: Talk to your health care provider.  

If your plan will not cover Revlimid next year, let your health care provider know right away. Ask if there is a different drug you can take that is on your plan’s formulary. For example, the formulary may include lenalidomide, the generic version of Revlimid. Talk to your provider about whether lenalidomide will work for you. If you and your provider agree that it won’t and there is no other suitable alternative to Revlimid, you can consider switching drug plans.   

Step 3: Consider changing how you get Medicare coverage before the end of Open Enrollment on December 7. 

While people are having trouble finding a Part D plan that covers Revlimid, many Medicare Advantage (Part C) plans include it on their 2025 formularies. During Medicare’s annual Open Enrollment period you can change how you get your Medicare coverage next year. Any change you make will become effective on January 1.  

You may decide that you want to switch from Original Medicare & a Part D plan to a Medicare Advantage plan that includes drug coverage (MA-PD.) This will not be the best choice for everyone, but is something to consider.  

• If you decide to switch to an MA-PD: 
  • Make sure that any providers you want to see are part of the MA-PD’s network 
  • Make sure any other drugs you take are covered by the MA-PD plan at a price you can afford and check whether Revlimid or any other drug you take has restrictions (e.g., quantity limits, prior authorization, or step therapy requirements). You can do this by using Plan Finder.  
  • Understand that if you have a Medigap plan, you cannot keep it if you move to a Medicare Advantage plan. Also, if you decide to return to Original Medicare in the future, you may not be able to get the Medigap plan back.  

What if someone doesn’t find out about this until after Open Enrollment ends? 

If you don’t realize that Revlimid isn’t covered by your Part D plan until after December 7, you still have options. 

Options if you have a Part D plan where Revlimid is off-formulary:  

Ask your health care provider for help. Note that you may only be able to take these steps once your Part D plan has started in January. 

• Request a transition fill.

During the first 90 days you are in a Medicare drug plan, the plan will typically provide a one-time, (at least) 30-day, temporary supply of a drug you were previously taking (1) if you just switched to a new drug plan; or (2) if you have remained in the same drug plan you previously had, but that plan no longer includes Revlimid on its formulary.  

• As soon as you request a transition fill, you should also request a formulary exception. This is a request to have Revlimid covered by your new plan as if it was on the plan’s formulary.  
  • To get a formulary exception, your health care provider must provide a supporting statement that Revlimid is medically necessary, because none of the drugs that are on your plan’s formulary would be as effective for you, and/or that the drugs on the formulary would have adverse effects.  
  • For example, your provider could share evidence that you previously tried lenalidomide & that you were allergic to it, or that it was not effective at treating your condition.  
  • You, your health care provider, and/or your pharmacist can also share information about the difficulty getting lenalidomide right now as there is currently a shortage. 
  • If you receive a formulary exception, then the out-of-pocket costs for the drug will count towards the $2,000 out-of-pocket maximum in 2025. 
• If your request for a formulary exception is denied, you can appeal, to ask your plan to reconsider its decision. For details about the appeals process, visit the Cancer Finances Health Insurance Appeals module. 

Options if you have a Part C plan where Revlimid is off-formulary: 

If you have a Medicare Advantage plan that does not include Revlimid on its formulary, you can also ask your health care provider for help, to participate in the same process above.  

• You can also decide to change plans during the Medicare Advantage Open Enrollment Period from January 1 to March 31. You can switch from one Medicare Advantage Plan to a different Medicare Advantage Plan that does include Revlimid on its formulary.  
• You can also switch from a Medicare Advantage Plan to Original Medicare, and enroll in a Part D plan for your drug coverage.  
  • But note that this Part D plan might not include Revlimid on its formulary either.  
  • If you do this, you will want to check if you can buy a Medigap plan. Not everyone will be able to do so. 

Where to get help comparing Medicare plan options? 

These resources can help with understanding and comparing Medicare plan options: 

• Triage Cancer’s Medicare & Cancer resources 
• Triage Cancer’s recorded webinar, Medicare 101  
• Each state has a state health insurance assistance program (SHIP) that provides free counseling to people with Medicare. Find contact information for your state’s SHIP here.

It is also important to realize that this is an evolving situation and there may be changes to how plans cover Revlimid between now and the beginning of the year. We will share updates with any information that we learn.  

© Triage Cancer 2024