Medicare and Aviane: What the Coverage looks like

Medicare Part D (prescription drug coverage) covers Aviane, a birth control pill containing norgestimate and ethinyl estradiol, but only if your specific plan includes it on its formulary — the list of drugs the plan will pay for. Not every Part D plan covers Aviane, and coverage rules vary by plan and by year. Some plans may require you to try a different birth control first, or may charge a higher copay for Aviane than for generic alternatives.

If you are enrolled in Original Medicare (Part A and B only) without a separate Part D plan, you have no prescription drug coverage at all, and you would pay the full retail price for Aviane out of pocket. If you are in a Medicare Advantage plan (Part C), that plan includes drug coverage, and Aviane may or may not be covered depending on which Advantage plan you chose.

The best way to find out whether your plan covers Aviane is to call the customer service number on the back of your insurance card, or to log into your plan's website and search the formulary directly. You can also contact your pharmacy — they can check your coverage in seconds.

Key Takeaways

  • Medicare Part D covers Aviane on most plans, but you must check your specific plan's formulary to confirm, because not all plans include it.
  • Your copay for Aviane depends on which tier your plan places it on — usually $10 to $50 per month, but this varies by plan.
  • If your plan does not cover Aviane, you can ask your doctor for a generic alternative (norgestimate-ethinyl estradiol), which is usually covered at a lower cost.
  • You can change your Part D plan during the annual enrollment period (October 15 to December 7) if your current plan stops covering Aviane or raises the copay too high.

How to check your plan's formulary for Aviane

Your plan's formulary is a public document you can access online or by phone. Go to your plan's website (the address is on your insurance card) and look for a link labeled "Formulary," "Drug List," or "Covered Medications." Search for "Aviane" by name. The formulary will tell you the tier (cost level), any prior authorization requirements, and whether quantity limits explore.

If you cannot find it online or prefer to speak with someone, call the customer service number on your card. Have your plan name and member ID ready. The representative can tell you the exact copay you would pay and whether your doctor needs to submit any paperwork before the pharmacy can fill the prescription.

Your pharmacy can also look this up for you. Call the pharmacy where you plan to fill the prescription and give them your insurance information — they will tell you the copay and whether the prescription is covered.

What to do if your plan does not cover Aviane

If Aviane is not on your plan's formulary, you have several options. The first is to ask your doctor whether a generic version of the same medication (norgestimate-ethinyl estradiol) is available. Generic versions are almost always covered and cost less — often $10 to $20 per month instead of $30 to $50.

The second option is to request a prior authorization from your doctor. Some plans require you to try a cheaper birth control first before they will cover Aviane. If your doctor believes Aviane is medically necessary for you, they can submit a prior authorization request to the plan, and the plan may approve coverage even though it is not on the formulary.

The third option is to wait for the annual enrollment period and switch to a different Part D plan that does cover Aviane. The enrollment period runs from October 15 to December 7 each year, and you can change plans once per year. Use the Medicare Plan Finder tool on Medicare.gov to compare plans and see which ones include Aviane on their formulary.

Copay amounts and cost-sharing for Aviane

Part D plans organize drugs into tiers, and your copay depends on which tier Aviane is on. Tier 1 (generic drugs) usually costs $5 to $15 per month. Tier 2 (preferred brand-name drugs) usually costs $25 to $50 per month. Tier 3 (non-preferred brand-name drugs) can cost $50 to $100 or more. Aviane, as a brand-name drug, typically falls into Tier 2 on most plans, but this varies.

Once you reach your plan's deductible (usually $505 to $560 per year, though this changes annually), you begin paying copays. After you and your plan have spent a combined total of $7,050 in 2024 (this amount changes each year), you enter the catastrophic coverage phase, where Medicare pays most of the cost and you pay a small copay.

If cost is a concern, ask your doctor about patient information programs run by the manufacturer. Allergan, which makes Aviane, may offer copay cards or free or reduced-cost medication to people who meet income requirements.

Using a Part D plan versus Original Medicare

If you have Original Medicare (Part A and B) without Part D, you are not covered for any prescription drugs, including Aviane. You would pay the full retail price. Most people with Original Medicare add a separate Part D plan to get drug coverage, and you can do this during the annual enrollment period or within 63 days of losing other drug coverage.

If you are in a Medicare Advantage plan (Part C), drug coverage is built in, and Aviane may or may not be covered depending on your specific Advantage plan. Check your plan's formulary the same way you would for Part D.

What happens if you cannot afford the copay

If your copay is too high, talk to your doctor about generic alternatives first. Norgestimate-ethinyl estradiol generics are usually much cheaper and work the same way as Aviane.

You can also look into the Medicare Extra Help program (also called the Low-Income Subsidy), which helps people with limited income and resources pay for Part D premiums and copays. You can find out whether you may have access to by calling 1-800-MEDICARE or visiting Medicare.gov. Some states also run pharmaceutical information programs that help cover the cost of specific drugs.

If you are not yet 65 and have Aviane covered under a commercial insurance plan, check whether you can stay on that plan or whether you must switch to Medicare when you turn 65. Some people can delay Medicare enrollment without penalty if they have employer coverage.

Switching plans if Aviane coverage changes

If your plan stops covering Aviane or raises the copay significantly, you can switch to a different Part D plan during the annual enrollment period (October 15 to December 7). Use the Medicare Plan Finder at Medicare.gov to search for plans that cover Aviane and compare the copays.

If your plan drops Aviane coverage mid-year (outside the enrollment period), you may be able to switch plans when ready without waiting. This is called a "may have access to life event" in some cases. Call Medicare at 1-800-MEDICARE to ask whether you are may be able to access for a special enrollment period.

Frequently Asked Questions

Does Medicare Part B cover Aviane?

No. Part B covers doctor visits and some medical equipment, but not prescription drugs. Only Part D covers Aviane. If you have Original Medicare without Part D, you have no coverage for birth control pills.

Can I get Aviane without a copay?

Some Part D plans cover certain preventive medications without a copay, but Aviane is not typically on that list. However, if your plan places Aviane on Tier 1 (generic tier), your copay may be very low — $5 to $10 per month. Check your plan's formulary to see what tier Aviane is on.

What if I switch from Aviane to a generic birth control to save money?

Generic norgestimate-ethinyl estradiol is chemically identical to Aviane and works the same way. The main difference is the tablet shape, color, and packaging. If cost is a barrier, switching to the generic is a safe and effective option. Talk to your doctor or pharmacist about the switch.

Can I order Aviane from Canada or online to save money?

Medicare does not cover prescriptions filled outside the United States, so ordering from Canada or other countries would not count toward your Part D deductible or out-of-pocket maximum. You would pay full price and get no credit toward your coverage limits. It is usually cheaper to use your Part D plan, even with a copay, than to buy outside the U.S. system.

What if my doctor says I need Aviane specifically and my plan will not cover it?

Ask your doctor to submit a prior authorization request to your plan. Explain to your doctor that you have tried other birth control options or that Aviane is medically necessary for you. The plan may approve coverage even though Aviane is not on the formulary. If the plan denies the request, you can appeal the decision.