Medicare's Coverage of Colazal

Medicare Part D covers Colazal (balsalazide), a medication used to treat ulcerative colitis, but whether you pay a copay or full price depends on which Part D plan you have and which tier Colazal sits on in that plan's formulary. Most plans do cover it, but some require you to try a less expensive medication first — a step called a prior authorization — before they will pay for Colazal. Original Medicare (Part A and B) does not cover prescription drugs; only Part D does.

The amount you pay out of pocket varies widely. Your plan's formulary — the official list of drugs it covers — places Colazal on a tier, usually tier 2 or tier 3, which determines your copay. Tier 1 drugs cost the least; tier 3 or 4 drugs cost more. Some plans may not list Colazal at all, which means you would pay the full retail price unless you switch plans or request an exception.

Key Takeaways

  • Medicare Part D covers Colazal on most plans, but your copay depends on which tier your specific plan places it on.
  • Some Part D plans require prior authorization, meaning your doctor must request approval before the plan will pay.
  • If your plan does not cover Colazal, you can ask your doctor to request an exception, switch to a different Part D plan during open enrollment, or look into manufacturer discount programs.
  • You can check your plan's formulary online or call the plan directly to find out your exact copay and whether prior authorization is required.
  • Colazal costs significantly more than some older ulcerative colitis medications, so your plan may ask you to try a cheaper option first.

How to Find Out What Your Plan Covers

The fastest way to learn whether your Part D plan covers Colazal and what you will pay is to check your plan's formulary online. Log into your plan's website (the name appears on your Medicare card) and search for "Colazal" or "balsalazide." The formulary will show you the tier, any prior authorization requirement, and your copay amount.

If you do not have internet access or prefer to speak with someone, call the customer service number on the back of your Medicare card. Have your prescription information ready — the dose and how many tablets or capsules you take — because the copay can vary by strength. A representative can tell you the copay, whether prior authorization is needed, and whether your doctor's office will need to contact the plan before the pharmacy can fill your prescription.

If you are shopping for a new Part D plan during open enrollment (October 15 to December 7 each year), use the Medicare Plan Finder tool at Medicare.gov. Enter Colazal and your pharmacy to compare copays across plans in your area. Plans change their formularies every year, so a drug that was covered last year may move to a higher tier or require prior authorization this year.

Prior Authorization and Step Therapy

Prior authorization means your doctor must contact your Part D plan and request approval before the plan will pay for Colazal. This usually takes a few business days. Your doctor's office handles the request, not you, but it is worth calling your plan ahead of time to ask whether prior authorization is required so there are no surprises at the pharmacy.

Some plans use step therapy, which means they will only pay for Colazal if you have already tried and failed a cheaper medication — usually mesalamine (Asacol, Pentasa) or sulfasalazine. If your plan requires step therapy, your doctor will need to document that you took the first-line drug and that it did not work well enough before the plan will cover Colazal. This process can add weeks to getting the medication you need.

If your doctor believes step therapy will delay necessary treatment, they can request an exception. The plan will review the medical reason and decide whether to waive the step therapy requirement. This is not automatic, but it is worth asking if your doctor thinks Colazal is the right choice for you right away.

What to Do If Your Plan Does Not Cover Colazal

If your Part D plan does not cover Colazal at all, you have three main options. First, ask your doctor to request a formulary exception. Your doctor writes to the plan explaining why Colazal is medically necessary for you and why other covered alternatives will not work. The plan reviews this and decides whether to cover it. This can take one to two weeks.

Second, you can switch to a different Part D plan during open enrollment if you find one that covers Colazal at a lower copay. You can also switch if you have a may have access to life event — such as moving to a new state, losing other insurance, or a significant change in your health. Call Medicare at 1-800-MEDICARE to ask whether your situation qualifies.

Third, check whether the manufacturer of Colazal offers a patient information program or discount card. Salix Pharmaceuticals, which makes Colazal, sometimes offers copay cards that reduce your out-of-pocket cost. Your doctor's office or the manufacturer's website can provide information about these programs. These programs are separate from Medicare and may help even if your plan does not cover the drug.

Colazal Cost and Generic Alternatives

Colazal is a brand-name medication and costs more than older ulcerative colitis drugs. The retail price is typically $300 to $500 per month before insurance, though your copay will be much lower. Generic balsalazide is available and costs less, but not all Part D plans cover the generic at a lower tier than the brand name.

Mesalamine (Asacol, Pentasa, Delzicol) is often the first medication doctors prescribe for mild to moderate ulcerative colitis and is usually covered at a lower copay than Colazal. Sulfasalazine is even cheaper and has been used for decades, though it causes more side effects in some people. If cost is a concern, ask your doctor whether one of these older options might work for you, or whether your plan will cover the generic version of balsalazide.

When to Contact Your Doctor or Plan

Contact your doctor if you have been taking Colazal and your symptoms are not improving, or if you are experiencing side effects. Do not stop taking it without talking to your doctor first, even if the copay is high or the prior authorization is taking time.

Contact your Part D plan if you receive a bill from the pharmacy that is higher than expected, if the pharmacy says your prescription was denied, or if you want to confirm your copay before filling the prescription. If you believe your plan made an error, you can file a complaint with Medicare by calling 1-800-MEDICARE or visiting Medicare.gov.

If you cannot afford your copay even with a manufacturer discount program, ask your doctor's office about samples or whether a social worker at your gastroenterology clinic can connect you with other resources. Some hospitals and community health centers have programs to help people pay for medications.

Frequently Asked Questions

Does Original Medicare cover Colazal?

No. Original Medicare (Part A and Part B) does not cover any prescription drugs. You must have Part D prescription drug coverage to have Medicare pay for Colazal. If you have Original Medicare and no Part D plan, you can enroll during the annual open enrollment period or if you have a may have access to life event.

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

You can, but it is usually not the best choice. If your Part D copay is lower than the GoodRx price, use your Part D plan. If your plan does not cover Colazal or the copay is very high, a GoodRx coupon might be cheaper. However, using a discount card instead of your insurance does not count toward your Part D deductible or out-of-pocket maximum, so it may cost you more overall.

What if I switch Part D plans and my new plan does not cover Colazal?

You can request a formulary exception from your new plan, or you can switch again during the next open enrollment period. If you are in the middle of treatment and your new plan does not cover your medication, call Medicare at 1-800-MEDICARE to ask about your options. In some cases, you may be able to make a mid-year change if the plan change caused a coverage problem.

Will my copay change if I take a higher dose of Colazal?

Possibly. Some plans charge different copays for different strengths or quantities. Check your formulary or call your plan to confirm the copay for the exact dose your doctor prescribed. If a higher dose has a much higher copay, ask your doctor whether a lower dose might work, or whether splitting pills is an option.

How do I know if my doctor's office submitted the prior authorization request?

Call your doctor's office and ask. They should have a record of when they sent it and can follow up with your Part D plan if it has been more than a few business days. You can also call your Part D plan directly and give them your name and prescription information; they can tell you whether a prior authorization request is pending.