Answering the Question: What Tier is Trikafta on?

October 10, 2025 •

4 min read

For Medicare prescription drug plans, the life-changing cystic fibrosis medication Trikafta is typically listed on Tier 5, the highest and most expensive tier of a formulary. This high-tier placement for specialty drugs like Trikafta is standard for most commercial insurance plans as well, largely due to its significant cost.

Quick Summary

Trikafta is a high-cost specialty medication, generally placed on the highest formulary tier (often Tier 5) by commercial and Medicare insurance plans, resulting in significant out-of-pocket costs for patients.

Key Points

Highest Formulary Tier: Trikafta is typically placed on the highest formulary tier (often Tier 4 or 5) as a specialty medication by most commercial and government insurance plans.
Significant Out-of-Pocket Costs: Due to its high-tier status, patients often face substantial out-of-pocket expenses, such as high coinsurance or large copayments, rather than fixed, low copayments.
Varies by Insurance Plan: The exact tier and cost-sharing amount for Trikafta can vary considerably depending on the specific insurance provider and individual plan's formulary.
Requires Prior Authorization: Many insurers require prior authorization before covering Trikafta, due to its high cost and specific criteria for eligibility.
Manufacturer Patient Assistance: The manufacturer, Vertex Pharmaceuticals, offers a patient assistance program (Vertex GPS) to help eligible commercially insured patients with the high cost of copayments.
Dispensed by Specialty Pharmacies: Trikafta must be dispensed by a specialty pharmacy, which often provides support in navigating insurance and prior authorization procedures.
Standard for High-Cost Drugs: Its high tier placement is not an arbitrary decision but a standard practice for managing access to expensive and complex specialty medications.

The Basics of Insurance Formularies and Drug Tiers

To understand why Trikafta is placed on a particular tier, it helps to know how insurance formularies work. A formulary is a list of prescription drugs covered by a health insurance plan. These lists are broken down into tiers, with each tier corresponding to a different level of cost-sharing for the patient. A lower tier number usually means a lower out-of-pocket cost (e.g., a small copayment), while a higher tier number means a higher cost (e.g., a larger copayment or coinsurance).

Generally, a basic formulary structure looks something like this:

Tier 1: Often includes low-cost generic drugs.
Tier 2: Typically consists of preferred brand-name drugs.
Tier 3: May include non-preferred brand-name drugs.
Tier 4/5 (Specialty): Reserved for high-cost, high-tech, and specialty drugs used to treat complex or rare conditions.

Since formularies are plan-specific, it is critical for patients to check their specific insurance policy's formulary to confirm a medication's tier.

Why Specialty Medications Like Trikafta are in the Highest Tiers

Trikafta is classified as a specialty medication for several reasons, which directly influence its placement on a high formulary tier:

High Cost: The annual list price for Trikafta is extremely high, exceeding $300,000 per year in some jurisdictions. Its manufacturing and research costs are a factor, contributing to the high price.
Rarity of Condition: It treats cystic fibrosis, a rare genetic disease. Medications for rare or orphan diseases are often more expensive due to smaller patient populations.
Clinical Complexity: The drug treats the underlying cause of cystic fibrosis and has complex administration and monitoring requirements.
Insurance Carrier Impact: As a high-cost medication, Trikafta contributes to increased overall plan spending and can influence premiums for all covered individuals.

What Tier is Trikafta on? A Closer Look

For most insurance plans, Trikafta is consistently placed on the highest formulary tier, often designated as a specialty tier.

For Medicare Prescription Drug Plans (Part D): Medicare plans typically list Trikafta on Tier 5, which is their specialty tier. This means that patients covered by Medicare Part D can expect to pay the highest level of cost-sharing, often through coinsurance or large copayments, though costs are capped during the catastrophic coverage phase.

For Commercial Insurance Plans: While the specific tier number can differ between insurance carriers, commercial plans almost universally place Trikafta in their highest, or specialty, drug tier. Like Medicare, these tiers are associated with the greatest out-of-pocket expenses for the patient. Many commercial plans also have restrictive prior authorization policies and quantity limits for high-cost medications like Trikafta.

Managing the High Cost of Trikafta

Despite its high list price and high-tier placement, several resources exist to help patients afford Trikafta.

Patient Assistance Programs: The manufacturer, Vertex Pharmaceuticals, offers the Vertex GPS™ program, which provides financial assistance to eligible commercially insured patients to help cover copay costs. Limits apply, but savings can be substantial.
Non-Profit Organizations: Foundations such as the HealthWell Foundation also have copay assistance programs for eligible individuals with cystic fibrosis.
Navigating Accumulator Programs: Some insurance plans use accumulator programs that do not count manufacturer copay assistance toward a patient's deductible or out-of-pocket maximum. This can leave patients with a significant and unexpected cost burden. Patients should carefully review their plan details regarding these programs.
State-Level Boards: In some areas, such as Colorado, Prescription Drug Affordability Boards (PDABs) may review and consider capping the price of high-cost drugs like Trikafta, though the process and outcomes can be complex.

Comparison of Drug Tiers


Feature	Tier 1 (Generic)	Tier 2 (Preferred Brand)	Tier 3 (Non-Preferred Brand)	Specialty Tier (e.g., Trikafta)
Drug Type	Low-cost generics	Brand-name drugs, often with no generic	Brand-name drugs with a generic option	High-cost, complex, specialized drugs
Cost-Sharing	Lowest patient cost, often a fixed copay (e.g., $10)	Higher than generics, fixed copay (e.g., $40)	Higher than preferred brands, potentially a higher copay or coinsurance	Highest patient cost, often a percentage-based coinsurance (e.g., 20%)
Coverage Rules	Minimal restrictions	Some restrictions possible	Often requires step therapy or prior authorization	Frequent prior authorization, quantity limits, and requires a specialty pharmacy

Navigating Your Specific Plan's Formulary

Since a drug's tier can vary from one plan to the next, it is crucial to take the following steps:

Locate your formulary: The easiest way is to check your insurer's website. Search for a link to their prescription drug list or formulary. These documents are also often available in your benefits package materials.
Contact your insurer: Call the member services number on your insurance card to speak with a representative. They can confirm Trikafta's specific tier on your plan and provide an estimate of your out-of-pocket costs.
Use online tools: Many insurers and pharmacy benefit managers (PBMs) offer online tools to search for a specific drug and its tier classification.
Work with a specialty pharmacy: Because Trikafta is a specialty medication, it is dispensed by specialized pharmacies. The specialty pharmacy staff can often help with insurance questions and navigate prior authorization requirements.

Conclusion

Trikafta is a highly effective medication for cystic fibrosis, but its cost and high formulary tier placement are significant hurdles for patients. Due to its status as a high-cost specialty drug, Trikafta is almost always found on the highest tier of insurance formularies, such as Tier 5 for Medicare plans. While this means substantial out-of-pocket expenses for patients, manufacturer-sponsored patient assistance programs and other support initiatives are available to help mitigate the financial burden. Understanding your specific insurance plan's formulary and utilizing all available resources are key steps toward managing the cost of this life-altering treatment.

For more detailed information on Trikafta and other cystic fibrosis treatments, the Cystic Fibrosis Foundation is an excellent resource.

Frequently Asked Questions

Trikafta is almost always placed on the highest formulary tier, often called the specialty tier. For many commercial plans, this is Tier 4 or 5, while for Medicare plans, it is typically Tier 5.

You can find your specific plan's formulary on your insurer's website, or by calling the member services number on your insurance card. The specialty pharmacy that dispenses Trikafta can also help you with this information.

A high tier means a higher out-of-pocket cost, which often comes in the form of a percentage-based coinsurance rather than a flat copayment. This can lead to significant costs, sometimes thousands of dollars per month, depending on your plan.

Yes, due to its high cost, most commercial and government insurance plans require prior authorization for Trikafta. The prior authorization process ensures the medication is medically necessary and that you meet the plan's coverage criteria.

Yes, Vertex Pharmaceuticals, the manufacturer of Trikafta, has a program called Vertex GPS™ that provides financial assistance for eligible commercially insured patients. Organizations like the HealthWell Foundation also offer copay assistance.

Accumulator programs are utilized by some insurance plans to prevent manufacturer copay assistance from counting toward a patient's deductible or out-of-pocket maximum. This can cause patients to face a large, unexpected payment once the manufacturer's assistance limit is reached.

Yes, because it is a specialty medication, Trikafta must be dispensed through a specialty pharmacy. These pharmacies are experts in handling high-cost medications and can assist with insurance issues.