Medicare covers bosentan, but only under specific conditions and through Part D prescription drug plans

Bosentan is a medication used to treat pulmonary arterial hypertension (PAH), a serious lung condition that makes it harder for your heart to pump blood through your lungs. Medicare Part D plans do cover bosentan, but whether your plan pays for it depends on the plan you chose, your income level, and whether your doctor's request meets the plan's requirements.

The coverage is not automatic. Your prescription drug plan maintains a list called a formulary that shows which medications it covers. Bosentan appears on most major plans' formularies, but it is usually placed in a higher cost tier, meaning you will pay more out of pocket than you would for a generic alternative. Some plans may also require prior authorization, which means your doctor must submit paperwork to the plan explaining why you need this specific drug before the plan will pay for it.

Key Takeaways

  • Bosentan is covered by most Medicare Part D prescription drug plans, but it is typically in a higher cost tier, so your out-of-pocket cost will be significant.
  • Your specific plan's formulary determines whether bosentan is covered and at what cost, so you need to check your plan documents or call the plan directly.
  • Many plans require prior authorization from your doctor before they will pay for bosentan, which can delay the start of treatment by a few days to a week.
  • If your plan does not cover bosentan or the cost is too high, you may be able to switch to a different Part D plan during the annual enrollment period or request a coverage exception.
  • Patient information programs run by the drug manufacturer may help reduce your cost if you meet income requirements.

How to learn about your plan covers bosentan

The fastest way is to call your Part D plan directly. The phone number is on your insurance card. Have your card handy and ask the representative whether bosentan is on your plan's formulary and what tier it is in. Tier 1 and Tier 2 are usually cheaper; Tier 3 and higher are more expensive. Ask also whether prior authorization is required.

You can also check online. Go to your plan's website and look for the formulary search tool. Type in "bosentan" and the tool will show you the tier and any restrictions. If you are not sure how to navigate the website, call the plan's customer service line — they can walk you through it.

If you do not yet have a Part D plan and are choosing one, use the Medicare Plan Finder tool at Medicare.gov. You can enter bosentan and see which plans in your area cover it and at what cost. This tool estimates your annual out-of-pocket costs for the medications you take, which helps you compare plans side by side.

What prior authorization means and how long it takes

Prior authorization is a requirement that your doctor submit a form to your insurance plan before the plan will agree to pay for the drug. The plan reviews the form to confirm that bosentan is medically necessary for your condition. This is not a denial — it is a verification step.

Your doctor's office usually handles the paperwork. Tell your doctor that your plan requires prior authorization and ask them to submit the request as soon as possible. The plan typically responds within 24 to 72 hours, though it can take up to a week. During this time, you cannot fill the prescription, so it is important to start the process early if you need the medication urgently.

If the plan denies the request, your doctor can appeal or request a coverage exception. This process takes longer — usually one to two weeks — so discuss with your doctor what to do if the initial request is denied.

Cost tiers and what you will pay out of pocket

Bosentan is an expensive medication, and most Part D plans place it in Tier 3, Tier 4, or Tier 5. The exact amount you pay depends on your plan and where you are in your coverage year.

In 2024, Part D plans have different cost structures. Some use copayments (a flat dollar amount per prescription), while others use coinsurance (a percentage of the drug's cost). For a high-cost drug like bosentan, coinsurance is more common, which means you might pay 25% to 33% of the drug's price. The monthly cost can range widely depending on your plan and the pharmacy you use.

Once you reach the coverage gap (sometimes called the "donut hole"), your costs change. In the gap, you pay a higher percentage of the drug's cost until you reach catastrophic coverage, where Medicare pays most of the cost. Your plan's summary of benefits document explains exactly how costs work at each stage.

Patient information programs that may help with cost

The manufacturer of bosentan, Actelion (now part of Johnson & Johnson), runs a patient information program for people who have trouble affording the drug. The program may provide bosentan at no cost or at a reduced cost if your income is below a certain threshold.

To learn about this program, ask your doctor or pharmacist, or call the manufacturer's patient services line. You will need to provide proof of income and insurance information. The process usually takes one to two weeks. This program is separate from Medicare and does not affect your Part D coverage.

Some nonprofit organizations that focus on pulmonary hypertension also offer copay information or grants. The Pulmonary Hypertension Association maintains a list of resources on its website. Your doctor's office may also know of local programs or foundations that help patients pay for medications.

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

If your current plan does not cover bosentan or places it in a tier that makes it unaffordable, you have options. During the annual enrollment period (October 15 to December 7 each year), you can switch to a different Part D plan that does cover bosentan at a lower cost. Use the Medicare Plan Finder tool to compare plans and see which ones offer better coverage for this drug.

If you need the medication before the next enrollment period, you can request a coverage exception. This is a formal request to your plan asking it to cover a drug that is not on the formulary or to move it to a lower tier. Your doctor must submit the request and explain why bosentan is medically necessary and why other covered alternatives would not work. The plan must respond within 72 hours for urgent requests.

Another option is to ask your doctor whether there are other medications for pulmonary arterial hypertension that your plan covers at a lower cost. There are several classes of PAH drugs, and some may be more affordable under your specific plan. Your doctor can help you weigh the benefits and risks of alternatives.

How Medicare Part D enrollment works if you do not have coverage yet

If you are turning 65 or newly may be able to access for Medicare and do not yet have a Part D plan, you must choose one during your initial enrollment period. This period is seven months long, starting three months before the month you turn 65 and ending three months after. If you miss this window, you may face a late enrollment penalty that increases your premiums permanently.

You can enroll in a Part D plan through Medicare.gov, by phone at 1-800-MEDICARE, or in person at a local Social Security office. When you enroll, you will choose from several plans offered in your area. Each plan has different premiums, deductibles, and formularies, so comparing them based on the medications you take — including bosentan — is important.

If you already have Part D coverage but want to switch plans because of bosentan coverage, you can do so during the annual enrollment period. You can also switch if you experience a may have access to life event, such as a move to a new state or a significant change in your income.

Frequently Asked Questions

Will Medicare Part B cover bosentan instead of Part D?

No. Bosentan is an oral medication (a pill), so it is covered under Part D prescription drug plans, not Part B. Part B covers medications that are injected or infused in a doctor's office or hospital. If you take bosentan at home by mouth, Part D is the correct coverage.

What happens if I cannot afford bosentan even with my Part D plan?

Talk to your doctor about the cost. They may be able to request a coverage exception from your plan, help you find a patient information program, or discuss whether a different PAH medication covered at a lower tier might work for you. Do not stop taking bosentan without talking to your doctor first, as this can worsen your condition.

Can I use a GoodRx coupon or discount card instead of my Part D plan?

You can, but it is usually not allowed to use both at the same time. If the discount price is lower than your Part D copay or coinsurance, paying out of pocket with a coupon may be cheaper. However, the cost does not count toward your Part D deductible or out-of-pocket maximum, so it may cost you more overall. Compare the prices before you decide.

Does bosentan have a generic version that might be cheaper?

Bosentan does have a generic version, which is typically less expensive than the brand name. Ask your pharmacist whether the generic is available and whether your plan covers it at a lower cost tier. Your doctor can also specify "generic preferred" on your prescription to encourage the pharmacy to dispense the generic.

What if I move to a different state — will my Part D coverage change?

Yes. Part D plans are offered by state, so if you move, your current plan may not be available in your new state. You will need to enroll in a new plan that serves your new address. You can do this outside the annual enrollment period if you move, so contact your plan or Medicare as soon as you know your new address.