Important changes to Medicare Advantage and Part D prescription drug plans
Starting Jan. 1, 2026, UnitedHealthcare® Medicare Advantage and stand-alone Medicare Part D prescription drug plans will make updates to coverage for certain drugs and change how members pay for prescription drugs on Tiers 3 and 4.
We want to share the following information to help you respond to questions you may receive from members about these plan and formulary (drug list) updates.
Copay changes
Beginning Jan. 1, 2026, instead of a fixed copay amount, members will now have to pay coinsurance on additional drug formulary tiers. After a member meets their prescription drug plan deductible (which varies by plan up to $615), coinsurance will apply to drugs on Tiers 3 and 4. Tiers 1 and 2, which include the most prescribed drugs, will continue to have fixed copays.
Members will continue to pay their copay and coinsurance amounts until they reach their $2,100 out-of-pocket maximum amount for prescription drugs in 2026. Both the out-of-pocket maximum and the maximum plan deductible are based on the amounts set annually by the Centers for Medicare & Medicaid Services.
Formulary updates
The following chart highlights key formulary updates for UnitedHealthcare’s Individual and select Employer Group Medicare Advantage plans, including non-SNPs, D-SNPs and C-SNPs as well as stand-alone Part D prescription drug plans.
| Therapeutic use | Non-formulary medication | Covered alternatives |
|---|---|---|
| Diabetes | Tresiba® | Lantus®, Lantus® SoloStar®, Toujeo® SoloStar®, Toujeo® Max SoloStar® |
| Autoimmune | Humira® | Humira biosimilars: adalimumab-AATY (unbranded Yuflyma), adalimumab-ADBM (unbranded Cyltezo) |
| Orencia® | Adalimumab-AATY, adalimumab-ADBM, Enbrel®, Otezla®, Rinvoq®, Skyrizi®, Steqeyma® (Stelara® biosimilar), Tremfya®, Xeljanz®, Yesintek® (Stelara biosimilar) | |
| Constipation | Motegrity® | Lubiprostone (generic Amitiza®), Linzess®, Trulance® |
| Muscle relaxant | Cyclobenzaprine 7.5mg (generic Flexeril) | Tizanidine 2mg and 4mg tablets (generic Zanaflex®) |
| Genetic disorder | Aralast® NP, Zemaira® | Prolastin®-C |
| Multiple sclerosis | Vumerity® | Bafiertam® |
| Allergies | Dymista® | Azelastine 0.1% nasal spray, fluticasone nasal spray, and Ryaltris® |
| Respiratory | Formoterol | Arformoterol |
| Pirfenidone 534mg tablet (generic Esbriet®) | Pirfenidone 267mg tablet (generic Esbriet) | |
| Bevespi Aerosphere® | Anoro® Ellipta, Stiolto® Respimat® | |
| Women’s health | Femring®, Imvexxy® | Estradiol, Estring®, Premarin®, Yuvafem® |
| Elestrin® | Estradiol gel 0.06% (generic Divigel®) |
Alternative coverage may vary by formulary. Please visit PreCheck MyScript® or our drug list resource to confirm covered alternatives.
How to help prepare members
You can use the following resources to help members with these upcoming plan and formulary changes:
- PreCheck MyScript: Helps identify prescription costs in real time and suggests clinically appropriate, lower-cost alternatives. You can get a prior authorization for medications, if required, or request approval for identified alternatives.
- Eligibility and referrals: Verify patient eligibility and determine benefits to help members understand their prescription drug cost share benefits.
Questions? We're here to help.
Connect with us through chat 24/7 in the UnitedHealthcare Provider Portal.
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