Medicare Coverage for Apriso: The Short Answer

Medicare Part D covers Apriso, a brand-name medication used to treat ulcerative colitis, but whether you pay nothing, a copay, or a percentage of the cost depends on your specific plan and which tier the plan places it on. Apriso is not covered by Medicare Part A or Part B. Most plans do cover it, but you will need to check your plan documents or call your plan's customer service line to find out your exact out-of-pocket cost.

The coverage picture also changes if you use a generic version called mesalamine, which may be cheaper or covered differently than the brand name. If your doctor prescribes Apriso specifically and your plan charges a high copay, you have options: asking your doctor to request a coverage exception, switching to a different Part D plan during open enrollment, or looking into patient information programs run by the manufacturer.

Key Takeaways

  • Apriso is covered by most Medicare Part D plans, but your copay or coinsurance amount depends on which tier your specific plan assigns to it.
  • You can find your plan's coverage and cost by checking your plan's formulary (the official list of covered drugs) on your plan's website or by calling the plan directly.
  • Generic mesalamine may be cheaper than brand-name Apriso and may be covered at a lower tier, so ask your doctor whether switching is an option.
  • If your plan's copay is too high, you can request a coverage exception from your plan, or switch plans during the annual open enrollment period in October and November.

How to Check What Your Plan Covers

Your Part D plan publishes a formulary — a list of all drugs it covers and what tier each one sits on. Tier 1 drugs (generics) usually cost the least; Tier 2 (preferred brand names) cost more; Tier 3 and above cost the most. Apriso typically lands on Tier 2 or Tier 3, though this varies by plan.

To find your plan's formulary, log into your plan's website using your member ID (on your insurance card), or call the customer service number on the back of your card. Have your pharmacy's name and phone number ready if you call, because the representative may ask where you plan to fill the prescription. Some plans charge different copays depending on whether you use a mail-order pharmacy or a local one.

If you cannot find the information online or by phone, ask your doctor's office to check with your plan. Many offices have staff who do this regularly and can tell you the copay in one call.

Generic Mesalamine vs. Brand-Name Apriso

Apriso is a brand name for the drug mesalamine, which is also sold as a generic. Generic mesalamine is chemically identical to Apriso but usually costs far less. Many Medicare Part D plans cover generic mesalamine on Tier 1, which means a lower copay than brand-name Apriso.

The main difference is the delivery system: Apriso uses a special coating designed to release the drug slowly in the colon, while some generic versions use different coatings or release mechanisms. Your doctor may have prescribed Apriso specifically because they believe the delivery system works better for your condition, or they may have straightforward written "Apriso" out of habit. It is worth asking your doctor whether generic mesalamine would work for you, especially if your plan charges a high copay for the brand name.

If your doctor says the brand name is medically necessary, you can ask them to write "Apriso — do not substitute" on the prescription, and then request a coverage exception from your plan (see below).

Requesting a Coverage Exception

If your plan does not cover Apriso, or covers it at a tier with a copay you cannot afford, you can ask your plan for a coverage exception. This is a formal request asking the plan to cover the drug anyway, usually because a generic or cheaper alternative did not work for you or caused side effects.

Your doctor must submit the request on your behalf. They will need to write a letter explaining why Apriso is medically necessary for you — for example, that you tried generic mesalamine and it did not control your symptoms, or that you had an allergic reaction to it. The plan then has 72 hours (or sometimes longer, depending on your situation) to say yes or no.

Ask your doctor's office to submit the request as soon as possible, because you may have to wait for an answer before you can fill the prescription. If the plan denies the request, you have the right to appeal, and your doctor can submit additional medical information to support the appeal.

Switching Plans to Lower Your Cost

If your current plan charges a high copay for Apriso and you cannot get a coverage exception, you can switch to a different Part D plan during the annual open enrollment period, which runs from October 15 to December 7 each year. Your new coverage begins January 1.

When you compare plans, use the Medicare Plan Finder tool on Medicare.gov. Enter Apriso (or mesalamine) in the drug search box, and the tool will show you which plans cover it and what the copay is for each plan. You can also see the plan's monthly premium and whether your pharmacy is in the plan's network. Some plans have lower premiums but higher drug copays, so compare the total cost — premium plus copay — not just one or the other.

If you miss the October-to-December window, you may still be able to switch if you may have access to for a Special Enrollment Period. This happens if you move, lose other insurance, or experience certain life changes. Call Medicare at 1-800-MEDICARE to ask whether you may have access to.

Patient information Programs

Apriso's manufacturer, Tillotson Healthcare, runs a patient information program that may cover part or all of your copay if your income is below a certain threshold. These programs are separate from Medicare and do not count as insurance; they are designed to help people who cannot afford their medications.

To learn whether you may have access to, visit the manufacturer's website or call their patient information line. You will need to provide proof of income and proof that you have Medicare. The program can take one to two weeks to process, so explore as soon as you know your copay will be high. If you are approved, the program will send a card or voucher to your pharmacy that covers your copay at the time you fill the prescription.

What Happens at the Pharmacy

When you fill an Apriso prescription, the pharmacy will check your Part D coverage in real time. If your plan covers it, the pharmacy will charge you the copay listed on your plan. If your plan does not cover it, the pharmacy will tell you the full price and ask whether you want to pay out of pocket or wait while they contact your doctor to discuss alternatives.

If you have already requested a coverage exception and are waiting for an answer, tell the pharmacy. Some will hold the prescription for a few days while the plan makes a decision. If the plan approves the exception, the pharmacy will charge your copay. If it denies the exception, you will have to decide whether to pay full price, ask your doctor for a different medication, or appeal the denial.

Frequently Asked Questions

Does Medicare Part A or Part B cover Apriso?

No. Part A covers hospital stays and Part B covers doctor visits and some medical equipment, but neither covers prescription drugs. Only Part D covers Apriso. If you do not have Part D, you can join a plan during the annual open enrollment period or if you may have access to for a Special Enrollment Period.

Will my copay for Apriso stay the same all year?

Usually yes, but your plan can change its formulary and copays once per year, typically in January. If your copay increases, you will be notified in advance and can switch plans during the next open enrollment period.

What if I cannot afford the copay even after requesting a coverage exception?

Check whether you may have access to for the manufacturer's patient information program, or ask your doctor whether a different medication might work for you. Some other ulcerative colitis drugs may be covered at a lower tier on your plan. You can also contact your local Area Agency on Aging or a patient advocacy organization for ulcerative colitis to ask about other financial resources.

Can I use a coupon or discount card for Apriso if I have Medicare?

No. Medicare rules prohibit using manufacturer coupons or discount cards if you have Part D coverage. You must use your Part D plan. However, you can use a coupon or discount card if you do not have Part D and are paying out of pocket.

What if my doctor prescribed Apriso but my plan only covers generic mesalamine?

Ask your doctor whether generic mesalamine would work for you. If they say yes, fill the generic prescription and pay the lower copay. If they say the brand name is medically necessary, ask them to submit a coverage exception request to your plan explaining why.