Medicare Part D covers Arava, but only if your plan includes it on its formulary and you meet the plan's cost-sharing rules

Arava (leflunomide) is a disease-modifying antirheumatic drug (DMARD) used to treat rheumatoid arthritis. Most Medicare Part D prescription drug plans do cover it, but coverage is not automatic — your specific plan decides whether to include Arava and at what cost to you. Some plans may require you to try a different medication first, or may place Arava in a higher cost tier that means you pay more out of pocket.

The amount you pay depends on three things: whether your plan's formulary lists Arava, which tier it is placed in, and whether your plan has prior authorization or step therapy rules. Prior authorization means your doctor must get approval from the insurance company before you fill the prescription. Step therapy means you may need to try and fail on another drug first. Both can delay treatment, so it is worth asking your plan directly before your doctor writes the prescription.

Key Takeaways

  • Most Medicare Part D plans cover Arava, but you must check your specific plan's formulary to confirm it is included.
  • Your out-of-pocket cost depends on which tier your plan places Arava in — typically ranging from a standard copay to a percentage of the drug's cost.
  • Some plans require prior authorization from your doctor's office before the pharmacy will fill the prescription, which can take several business days.
  • If your plan does not cover Arava or places it in an expensive tier, you can switch to a different Part D plan during the annual enrollment period in October and November.

How to check if your plan covers Arava

The fastest way is to call the customer service number on the back of your Medicare card. Tell them you take or plan to take Arava and ask: Is it on the formulary? What tier is it in? Do you need prior authorization? The representative can answer all three in one call and tell you your exact copay or coinsurance amount.

You can also check online. Log into your plan's website (the name is on your card) and look for "Formulary" or "Drug List." Search for "leflunomide" or "Arava" — some plans list both the generic and brand name. The formulary will show the tier and any restrictions. If you cannot find it online or the website is unclear, calling is faster than searching.

What tier your plan places Arava in affects your cost

Medicare Part D plans typically have four or five tiers. Tier 1 and 2 are usually generic drugs with low copays. Tier 3 is usually brand-name drugs with higher copays. Tier 4 and 5 (if your plan has them) are specialty drugs or non-preferred brands, where you may pay 25 to 33 percent of the drug's cost instead of a flat copay.

Arava is a brand-name drug, so most plans place it in Tier 3 or Tier 4. If your plan puts it in Tier 3, you might pay $35 to $75 per month. If it is in Tier 4, you could pay $100 to $200 or more, depending on the drug's price and your plan's coinsurance percentage. The only way to know your exact cost is to check your plan's formulary or call customer service.

Prior authorization and step therapy can delay your prescription

Some Medicare Part D plans require prior authorization before covering Arava. This means your rheumatologist's office must submit a form to the insurance company explaining why you need the drug. The plan then approves or denies it, usually within 24 to 72 hours. If approved, you can fill the prescription. If denied, your doctor can appeal or try a different medication.

Other plans use step therapy, which means you must try a different DMARD first — often a cheaper one like methotrexate — and show that it did not work before the plan will cover Arava. Step therapy can add weeks or months to treatment. Ask your doctor's office to check whether your plan requires either of these before writing the prescription. If your plan has step therapy and you have already tried the required drug, your doctor can document that and request an exception.

What to do if your plan does not cover Arava or the cost is too high

If Arava is not on your plan's formulary at all, or if the copay is unaffordable, you have options. First, ask your doctor whether a generic DMARD like methotrexate or sulfasalazine would work for you — these are usually cheaper and covered by all plans. Second, ask your doctor to request a formulary exception from your plan. If your doctor explains that you have tried other drugs and only Arava works, the plan may cover it even if it is not on the formulary.

Third, you can switch to a different Medicare Part D plan. Every year from October 15 to December 7, you can change plans during the Annual Enrollment Period. Use the Medicare Plan Finder tool on Medicare.gov to compare plans and see which ones cover Arava at the lowest cost. If you switch, the new coverage starts January 1. If your situation changes mid-year — for example, your doctor prescribes Arava and your current plan will not cover it — you may be able to switch outside the enrollment period. Call Medicare at 1-800-MEDICARE to ask about a Special Enrollment Period.

Patient information programs can lower your out-of-pocket cost

The manufacturer of Arava, Sanofi, offers a patient information program for people who cannot afford the drug. You may be able to get Arava for free or at a reduced cost if your income is below a certain level. Ask your doctor's office to help you find and fill out the process, or visit the Sanofi website and search for "patient information." Your pharmacist can also tell you whether you may have access to.

Some nonprofit organizations, like the Arthritis Foundation, also offer co-pay information cards that can lower your out-of-pocket cost at the pharmacy. These are separate from your insurance and can be used alongside your Medicare plan. Ask your rheumatologist's office whether they know of any programs you might be may be able to access for.

Frequently Asked Questions

Does Medicare Part B cover Arava?

No. Part B covers drugs given by injection or infusion in a doctor's office or hospital. Arava is a pill you take at home, so it is covered only by Part D, the prescription drug plan. If you do not have Part D, you should consider joining one during the next enrollment period.

What if I cannot afford the copay even after checking my plan?

Talk to your doctor about whether a generic DMARD would work instead — these usually have lower copays. You can also ask about the manufacturer's patient information program or nonprofit co-pay cards. If your income is very low, you may may have access to for Extra Help, a federal program that lowers Part D costs. Call 1-800-MEDICARE to ask about it.

Can my doctor override my plan if it denies Arava?

Your doctor can request a formulary exception or appeal the denial, but the plan makes the final decision. If the appeal is denied, your doctor can prescribe a different DMARD or you can switch to a plan that covers Arava. Switching plans is often faster than appealing.

Will switching Medicare plans in the fall affect my current prescriptions?

Your current prescriptions stay active until December 31. Your new plan's coverage starts January 1. If you need Arava before then, your current plan covers it. If you switch and your new plan does not cover Arava, you have 30 days after the switch to request a transition supply from your new plan while you and your doctor work out an alternative.