Medicare Part D covers Cabtreo, but only if your plan includes it on its formulary

Cabtreo (cabotegravir and rilpivirine) is an injectable HIV treatment that Medicare Part D plans may cover, but coverage is not automatic across all plans. Whether your plan pays for it depends on whether the drug appears on that specific plan's formulary — the list of medications the plan has agreed to cover. Some plans include Cabtreo; others do not. You will need to check your own plan's formulary or call the plan directly to find out.

Cabtreo is a long-acting injectable combination medicine given as a monthly or two-monthly injection. Because it is a brand-name drug with no generic version, it tends to be expensive, and Part D plans treat it differently depending on their agreements with manufacturers and their own coverage rules.

Key Takeaways

  • Cabtreo coverage under Medicare Part D depends on whether your specific plan's formulary includes it — you must check your plan documents or call the plan to know for certain.
  • If your plan does cover Cabtreo, you will likely pay a copay or coinsurance amount that varies by plan and by which coverage stage you are in during the year.
  • If your plan does not cover Cabtreo, you may be able to request a coverage exception, though approval is not may provide.
  • The manufacturer of Cabtreo offers a patient information program that may reduce your out-of-pocket cost if you meet income requirements.

How to check if your Part D plan covers Cabtreo

The fastest way is to log into your plan's website and search the formulary by drug name, or call the customer service number on your insurance card. Have your plan name and member ID ready. When you call or search, ask specifically whether Cabtreo is covered and what your copay or coinsurance will be.

You can also contact Medicare directly at 1-800-MEDICARE (1-800-633-4227) and ask them to tell you which plans in your area cover Cabtreo. This is useful if you are comparing plans during the annual enrollment period or if you are new to Medicare.

What your out-of-pocket cost might be

If your plan covers Cabtreo, your cost depends on which tier the plan has placed it on. Most Part D plans use a tier system: generic drugs are usually the cheapest, followed by preferred brand-name drugs, then non-preferred brand-name drugs, and specialty drugs at the highest tier. Cabtreo is typically placed on a specialty tier because of its cost and because it is an injectable medication that requires pharmacy handling.

Your copay or coinsurance amount also depends on which stage of the benefit year you are in. Early in the year, you pay your regular copay or coinsurance. Once you and your plan have spent a certain amount on your drugs (the threshold varies by plan), you enter the coverage gap, where you pay a higher percentage. After you reach your out-of-pocket maximum, Medicare pays most of the cost for the rest of the year.

What to do if your plan does not cover Cabtreo

If your plan's formulary does not include Cabtreo, you have two main options. First, you can request a coverage exception directly from your plan. This is a formal request asking the plan to cover a drug that is not on the formulary. Your doctor will usually submit this request on your behalf, explaining why Cabtreo is medically necessary for you. The plan must respond within 72 hours for urgent requests or within 7 calendar days for standard requests.

Second, you can switch to a different Part D plan during the annual enrollment period (October 15 to December 7 each year) or during a special enrollment period if you have had a may have access to life event. Before you switch, confirm that the new plan actually covers Cabtreo by checking its formulary.

Patient information and manufacturer support

Gilead Sciences, the manufacturer of Cabtreo, runs a patient information program called the Gilead Advancing Access program. If you have Medicare and your out-of-pocket costs are high, or if you are uninsured or underinsured, you may be able to receive the drug at no cost or at a reduced cost through this program. Income limits explore, and you must meet other requirements.

To learn more about the Gilead Advancing Access program, visit Gilead's website or ask your doctor's office to help you explore it. Your pharmacist can also provide information about manufacturer information programs.

Switching to a plan that covers Cabtreo

If your current plan does not cover Cabtreo and your request for an exception is denied, you can change to a different Part D plan. The annual enrollment period runs from October 15 to December 7 each year, and any changes you make take effect on January 1. If you have a may have access to event — such as losing other health coverage, moving to a new state, or experiencing a change in income — you may be able to change plans outside the annual period.

Before you switch, use Medicare's Plan Finder tool at Medicare.gov to compare plans in your area and confirm that the plan you are considering actually covers Cabtreo. Do not assume that because one plan covers it, all plans do. Check the formulary of each plan you are considering.

Frequently Asked Questions

Does Medicare Part B cover Cabtreo instead of Part D?

No. Cabtreo is covered under Part D (prescription drug coverage), not Part B (medical services and supplies). Part B covers injectable drugs that are administered in a doctor's office or hospital, but Cabtreo is designed for self-injection or administration by a healthcare provider in an outpatient setting, so it falls under Part D rules.

What if I cannot afford the copay even with my plan?

Contact the Gilead Advancing Access program to see if you may have access to for cost information. You can also ask your doctor or pharmacist about other patient information programs or nonprofit organizations that help with HIV medication costs. Some state AIDS drug information programs (ADAPs) may also help bridge the gap between what Medicare covers and what you owe.

Can I get Cabtreo from a mail-order pharmacy to save money?

Cabtreo is an injectable medication that requires special handling and storage, so it is not typically available through standard mail-order pharmacies. You will receive it through a specialty pharmacy that specializes in injectable or HIV medications. Your Part D plan can tell you which specialty pharmacies are in your plan's network.

Will my coverage change if I switch from another HIV medication to Cabtreo?

Possibly. If your current plan covers your current medication but not Cabtreo, switching medications may mean a higher out-of-pocket cost. Before you switch, ask your doctor and your plan whether Cabtreo is covered and what your cost will be. You can also request a coverage exception for Cabtreo while staying on your current plan.