Medicare Coverage for Delzicol: The Short Answer

Medicare Part D (prescription drug coverage) may cover Delzicol, but whether your plan does depends on which specific plan you have chosen and what that plan's formulary includes. Delzicol is a brand-name medication used to treat ulcerative colitis and Crohn's disease. Most Medicare plans cover it, but some require you to try a generic alternative first, pay a higher copay, or get prior authorization from your doctor before the pharmacy will fill the prescription.

The fastest way to find out what your plan covers is to call the member services number on the back of your Medicare card, or log into your plan's website and search the formulary (the list of covered drugs). You can also ask your pharmacist to check your coverage when you bring in a prescription.

Key Takeaways

  • Delzicol coverage varies by Medicare Part D plan, so you must check your specific plan's formulary to know what you will pay.
  • Many plans cover the generic version (mesalamine) at a lower cost than the brand-name Delzicol, and your doctor may need to request an exception if you need the brand specifically.
  • Prior authorization — a requirement that your doctor get approval from the insurance company before you fill the prescription — is common for Delzicol and can delay your first fill by a few days.
  • If your plan does not cover Delzicol or the copay is too high, you can switch to a different Medicare Part D plan during the annual open enrollment period (October 15 to December 7).

How to Check Your Plan's Delzicol Coverage

Your Medicare Part D plan publishes a formulary — a list of all drugs the plan covers and what tier (cost level) each drug sits on. Tier 1 drugs cost the least; Tier 5 drugs cost the most. Delzicol is usually a Tier 3 or Tier 4 drug, meaning you will pay more than you would for a generic.

To find your plan's formulary, go to your plan's website (the address is on your Medicare card or in your welcome materials) and search for "formulary" or "drug list". Type "Delzicol" into the search box. The result will show you the tier, the copay amount, and whether prior authorization is required. If you do not have internet access, call the member services number on your card and ask a representative to look it up for you.

Write down the copay amount and any restrictions (prior authorization, step therapy, quantity limits) so you can discuss them with your doctor before the prescription is written.

Prior Authorization and Step Therapy Requirements

Many Medicare Part D plans require prior authorization for Delzicol, meaning your doctor must contact the insurance company and get approval before the pharmacy can fill the prescription. This is not a denial — it is a verification step. The insurance company wants to confirm that the medication is medically necessary and that you have not already tried a cheaper alternative that would work.

Some plans also use step therapy, which means you must try and fail on a generic mesalamine (the active ingredient in Delzicol) before the plan will cover the brand-name version. If your doctor believes you need Delzicol specifically — for example, because you have had a bad reaction to generic mesalamine — they can request an exception. This takes a few extra days but is often approved.

Ask your doctor's office to handle the prior authorization request. Most offices do this routinely and can often get approval within 24 to 48 hours. If the request is denied, your doctor can appeal or request a coverage exception.

Generic Mesalamine as a Lower-Cost Alternative

The generic version of Delzicol is mesalamine (also called 5-ASA). Most Medicare Part D plans cover generic mesalamine at a much lower copay than brand-name Delzicol — often Tier 1 or Tier 2. If your plan covers mesalamine but not Delzicol, or if the Delzicol copay is very high, ask your doctor whether generic mesalamine would work for you.

Delzicol and generic mesalamine contain the same active ingredient, but Delzicol uses a different coating and delivery system that some patients tolerate better. If you have tried generic mesalamine in the past and it did not work for you, tell your doctor — they can document this and request that your plan cover Delzicol as a medical exception.

If cost is the main barrier, do not skip doses or stop taking the medication. Talk to your doctor or pharmacist about the generic option, patient information programs, or switching plans during open enrollment.

What to Do If Your Plan Does Not Cover Delzicol

If your current Medicare Part D plan does not cover Delzicol, or the copay is unaffordable, you have several options. First, ask your doctor to request a coverage exception — many plans will approve this if your doctor explains why you need the brand-name drug. Second, you can switch to a different Medicare Part D plan that does cover Delzicol.

You can change Part D plans only during the annual open enrollment period, which runs from October 15 to December 7 each year. During this window, you can drop your current plan and join a new one with coverage that starts January 1. Use the Medicare Plan Finder tool on Medicare.gov to compare plans in your area and see which ones cover Delzicol and at what cost.

If you need Delzicol before open enrollment and your plan does not cover it, ask your pharmacist about manufacturer coupons or patient information programs. Delzicol's manufacturer sometimes offers copay cards that reduce your out-of-pocket cost, even if your insurance does not cover the drug.

Costs and Copay Amounts

Delzicol copays vary widely depending on your plan and your stage of coverage. In 2024, copays for Tier 3 or Tier 4 drugs typically range from $35 to $100 per prescription, but some plans charge more. Once you reach the coverage gap (the "donut hole"), your copay may increase temporarily until you reach catastrophic coverage.

If you are on a limited income, you may be able to reduce your costs through the Medicare Extra Help program (also called the Low-Income Subsidy), which helps people with incomes below a certain threshold pay for Part D drugs. You can learn whether you may have access to by calling 1-800-MEDICARE or visiting Medicare.gov.

Keep in mind that copay amounts change each year, and plans change their formularies annually. Review your coverage each fall during open enrollment to make sure your plan still covers Delzicol at a cost you can afford.

How to Get Your Prescription Filled

Once you know your plan covers Delzicol, ask your doctor to write the prescription. Give the prescription to your pharmacy (mail-order or retail) along with your Medicare card. If prior authorization is required, the pharmacy will usually submit the request on your behalf and call you when it is approved.

If the pharmacy says the prescription cannot be filled because of prior authorization or a step-therapy requirement, do not assume it is denied. Ask the pharmacy to tell you exactly what the insurance company needs. Often it is just a phone call from your doctor's office. If your doctor's office is slow to respond, call them directly and ask them to prioritize the request.

For ongoing refills, set up automatic refills through your pharmacy if possible. This prevents gaps in your medication and makes it easier to track whether your copay has changed.

Frequently Asked Questions

Does Medicare Part B cover Delzicol?

No. Part B covers doctor visits, hospital care, and some medical equipment, but not prescription drugs taken at home. Delzicol is covered only under Part D (prescription drug coverage) or Part C plans that include drug coverage.

What if I cannot afford the copay?

Ask your doctor or pharmacist about manufacturer copay cards, which can reduce your out-of-pocket cost. You can also ask whether generic mesalamine would work for you, as it usually costs less. If your income is low, the Medicare Extra Help program may pay part or all of your drug costs.

Can I use a GoodRx coupon instead of my Medicare insurance?

You can, but it is usually not allowed to use both at the same time. If a GoodRx price is lower than your Medicare copay, you can pay cash using the coupon, but this will not count toward your Part D deductible or out-of-pocket maximum. Ask your pharmacist to compare the two prices before you decide.

What happens if I switch Medicare plans mid-year?

You cannot switch Part D plans except during the annual open enrollment period (October 15 to December 7) or if you have a may have access to life event (such as losing employer coverage). If you need a different plan urgently, contact Medicare to ask whether you may have access to for a special enrollment period.

Will my copay stay the same next year?

No. Medicare plans change their formularies and copay amounts every January. Review your coverage each fall during open enrollment to see whether Delzicol is still covered and what the new copay will be. If the cost becomes unaffordable, you can switch to a different plan.