Does Medicare Cover Lorbrena? Part D Costs and Assistance

Yes — Medicare does cover Lorbrena for most beneficiaries who need it, through Part D prescription drug plans. Coverage almost always comes with prior authorization, and some plans add step therapy requirements. Because the drug retails for more than $21,000 a month, the practical question is what you will pay out of pocket, and in 2026 that amount is capped at $2,100 for the year under Part D.

Why Lorbrena Falls Under Part D, Not Part B

Lorbrena (lorlatinib) is an oral targeted therapy for adults with ALK-positive metastatic non-small cell lung cancer. You pick it up at a pharmacy and take it at home, which places it under Medicare Part D, the prescription drug benefit.

Part B does pay for a narrow set of oral cancer drugs, but only when the oral version shares an active ingredient with an injectable chemotherapy drug Part B already covers.¹ Lorbrena has no injectable equivalent, so it does not qualify.² That means your Part D plan — whether a stand-alone prescription drug plan or the drug portion of a Medicare Advantage plan — is the one that pays.

Whether your specific plan lists Lorbrena on its formulary varies. Some plans include it directly. Others classify it as non-formulary but still cover it when clinical criteria are met. Kaiser Permanente Northwest, for example, treats Lorbrena as non-formulary and approves it through a criteria-based program that requires an oncologist prescriber, a confirmed metastatic NSCLC diagnosis, and molecular testing showing an ALK or ROS1 rearrangement.³ The only reliable way to know how your plan handles it is to check the formulary or call the plan.

What Your Plan Will Likely Require Before Paying

Almost every Part D plan that covers Lorbrena requires prior authorization. Your oncologist’s office submits documentation of your diagnosis, your ALK test results, and your treatment history, and the plan decides whether the clinical criteria are met.

Some plans add step therapy on top of prior authorization. A UnitedHealthcare step-therapy policy effective February 2026 requires members new to Lorbrena to have tried and failed, or have a documented contraindication to, two of the following: alectinib, brigatinib, or ensartinib.⁴ Patients already on Lorbrena based on claims history are generally allowed to continue without meeting that requirement.

Other plans permit Lorbrena as initial therapy, consistent with its FDA-approved first-line indication. Cigna’s national formulary policy, reviewed in December 2025, requires prior authorization and clinical documentation but does not require failure on another ALK inhibitor first for ALK-positive patients.⁵ Your plan documents control.

If Your Plan Denies the Prescription

You can ask the plan for an exception. A formulary exception asks the plan to cover a drug that is not on its list, or to waive a step therapy or similar requirement. A tiering exception asks for a lower cost-sharing level. Both require a supporting statement from your prescribing oncologist explaining why the covered alternatives are not medically appropriate for you.⁶

Plans must answer a standard exception request within 72 hours and an expedited request within 24 hours. If the plan still says no, you can appeal — the first step is a redetermination by the plan itself.⁷

What You’ll Actually Pay in 2026

Here is the number that matters most. For 2026, Medicare Part D caps your annual out-of-pocket drug spending at $2,100.⁸ That cap includes your deductible (up to $615 in 2026), copayments, and coinsurance. Once you’ve paid $2,100, you owe nothing more for covered Part D drugs the rest of the year.⁹

For a drug this expensive — roughly $21,915 for 30 tablets of the 100 mg strength¹⁰ — one month’s fill will typically push you straight through the deductible and the 25% initial-coverage coinsurance and up to the cap. In practical terms, you’re likely to hit the full $2,100 on your very first fill of the year.

Before the Inflation Reduction Act removed catastrophic-phase coinsurance, patients on drugs like Lorbrena had no ceiling at all on annual costs.¹¹ The cap is a meaningful change for anyone starting treatment now.

Spreading That $2,100 Across the Year

Facing the full cap at the pharmacy counter in January is still a shock for many people. The Medicare Prescription Payment Plan, launched in 2025, lets you spread your out-of-pocket costs into monthly installments across the calendar year. There is no interest and no enrollment fee.¹²

Enrollment is voluntary. You sign up by contacting your Part D plan by phone or online; you can’t do it at the pharmacy counter. Once enrolled, you stop paying at the pharmacy and receive a monthly bill from the plan. If you enroll from the start of the year and hit the full $2,100 cap, you’d pay roughly $175 per month.¹³ Falling two or more months behind can get you disenrolled, though you can rejoin after settling the balance.¹⁴

The payment plan doesn’t lower your total costs. It just changes when you pay.

Programs That Can Lower Your Cost Further

Even $2,100 is real money on a fixed income. Several programs can reduce it or eliminate it.

Medicare Extra Help

Extra Help, the federal low-income subsidy, is the single most valuable program for beneficiaries who qualify. It eliminates Part D premiums and deductibles, caps copays at $5.10 for generics and $12.65 for brand-name drugs in 2026, and once total drug costs reach $2,100, you pay nothing for the rest of the year.¹⁵

For 2026, you qualify as an individual with income at or below $23,940 and resources no higher than $18,090. Married couples qualify at $32,460 in income and $36,100 in resources. People enrolled in Medicaid, SSI, or a Medicare Savings Program are enrolled automatically; everyone else applies through the Social Security Administration, with no deadline.¹⁶

Pfizer’s Patient Assistance Program

One boundary worth stating up front: Pfizer’s Lorbrena copay card is not available to Medicare patients. Federal law prohibits manufacturer copay assistance for anyone on a government health program, and Pfizer’s terms explicitly exclude Medicare, Medicaid, TRICARE, and VA beneficiaries.¹⁷

A separate program, the Pfizer Patient Assistance Foundation, can provide Lorbrena at no cost to eligible patients, including those on Medicare. Eligibility requires household income at or below 300% of the Federal Poverty Level, a valid prescription, and proof of income. Medicare Part D and Medicare Advantage patients also have to document enrollment in the Medicare Prescription Payment Plan and certify they have not yet met their annual out-of-pocket maximum.¹⁸ Note that drugs received through this program can’t also run through the Medicare Prescription Payment Plan for billing, because the payment plan only applies to drugs processed through Part D.¹³

Independent Charitable Foundations

Several independent foundations offer copay grants to Medicare patients being treated for NSCLC. Their funds open and close based on donations, so check current status before counting on one.

The PAN Foundation runs a Non-Small Cell Lung Cancer fund that lists Lorbrena among covered medications. Initial grants are $4,800, with up to $9,600 per year, for government-insured patients with income at or below 500% of the Federal Poverty Level. As of mid-2026 the fund is closed but is accepting wait-list signups.¹⁹
The HealthWell Foundation runs a Non-Small Cell Lung Cancer – Medicare Access fund with a maximum award of $6,000, open to Medicare beneficiaries with income within 500% of the Federal Poverty Level.²⁰
The CancerCare Co-Payment Assistance Foundation assists with copayments for chemotherapy and targeted therapies, subject to current funding.²¹

Charitable copay grants can generally be used alongside the Medicare Prescription Payment Plan. The grant reduces what you owe at the pharmacy, which in turn reduces the balance billed through the payment plan.¹³

Steps to Take Now

Call your Part D plan or check its online formulary to confirm Lorbrena is covered and to identify any prior authorization, step therapy, or quantity limits.
Make sure your oncologist’s office has submitted the required molecular testing results and treatment history with the prior authorization.
If the plan denies coverage or imposes step therapy your oncologist considers inappropriate, have the oncologist file an exception request with a supporting clinical statement. Standard decisions are due within 72 hours, expedited ones within 24.⁶
If you’d rather pay in monthly installments than face the cap all at once, enroll in the Medicare Prescription Payment Plan through your plan before or shortly after your first fill.¹²
If your income and resources are limited, apply for Extra Help at 1-800-772-1213 or on the Social Security Administration website. There’s no deadline.¹⁶
Check the PAN Foundation and HealthWell Foundation websites for NSCLC fund status, and sign up for alerts if they’re closed.
If your household income is at or below 300% of the Federal Poverty Level, apply to the Pfizer Patient Assistance Program for free Lorbrena.¹⁸

1
CMS. Oral Anticancer Drugs Policy Article
2
Noridian Medicare. Oral Anticancer Drugs and Oral Antiemetic Drugs
3
Kaiser Foundation Health Plan of the Northwest. Lorbrena Criteria-Based Consultation Prescribing Program
4
UnitedHealthcare. Step Therapy – Lorbrena
5
Cigna. Coverage Position Criteria – Oncology – Lorbrena
6
CMS. Medicare Prescription Drug Plan Exceptions
7
Medicare.gov. Drug Plan Appeals
8
Medicare.gov. Before You Choose a Payment Option
9
PAN Foundation. Understanding the Medicare Part D Cap
10
Drugs.com. Lorbrena Prices, Coupons, and Patient Assistance Programs
11
MedicareResources.org. How Will the Inflation Reduction Act Affect Medicare Enrollees
12
Medicare.gov. Medicare Prescription Payment Plan
13
PAN Foundation. Understanding the Medicare Prescription Payment Plan
14
AARP. Medicare Prescription Payment Plan
15
Medicare.gov. Get Help With Drug Costs
16
Social Security Administration. Medicare Part D Extra Help
17
Lorbrena.com. Support and Resources
18
Pfizer. Pfizer Patient Assistance Program Enrollment Form
19
PAN Foundation. Non-Small Cell Lung Cancer Fund
20
HealthWell Foundation. Non-Small Cell Lung Cancer – Medicare Access
21
CancerCare. How Co-Payment Assistance Foundations Help