Medicare's Coverage of Kariva

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

If you are under 65 and on Medicare because of disability or end-stage renal disease, you have the same Part D options as anyone else. If you are 65 or older, you chose a Part D plan during your initial enrollment or during the annual open enrollment period (October 15 to December 7 each year). Your current plan's formulary determines what you pay.

Key Takeaways

  • Kariva is covered by some Medicare Part D plans but not all, so you need to check your specific plan's formulary to know whether it is covered.
  • Your plan may require prior authorization from your doctor before paying for Kariva, or may ask you to try a generic birth control pill first.
  • You can see your plan's formulary on your plan's website, in your member handbook, or by calling the customer service number on your insurance card.
  • If your plan does not cover Kariva or charges too much, you can switch to a different Part D plan during open enrollment or request a coverage exception from your current plan.

How to Check Your Plan's Formulary

The fastest way to find out whether your plan covers Kariva is to look at your plan's formulary online. Go to your plan's website (the address is on your insurance card or in your member handbook) and search for "formulary" or "drug list." Search for Kariva by name. The formulary will show you the copay amount, whether prior authorization is required, and whether the plan has any restrictions.

If you cannot find it online or prefer to ask directly, call the customer service number on your insurance card. Have your member ID ready. Tell the representative you want to know whether Kariva is covered under your plan and what your copay would be. Ask specifically whether prior authorization is required — this means your doctor must request permission from the plan before the pharmacy can fill the prescription.

Prior Authorization and Step Therapy

Some Medicare Part D plans use prior authorization, which means your doctor must submit a request to the plan before the pharmacy can fill your Kariva prescription. This usually takes a few business days. Your doctor's office typically handles this request, but you may need to follow up if the plan does not respond quickly.

Other plans use step therapy, also called fail-first. This means the plan will only pay for Kariva if you have already tried and failed on a cheaper birth control option — usually a generic pill. If your plan has step therapy for Kariva, your doctor will need to document that you tried another birth control first and that it did not work for you before the plan will cover Kariva.

Ask your doctor's office to check with your plan about these requirements before you fill the prescription. This prevents delays and surprises at the pharmacy.

What to Do If Your Plan Does Not Cover Kariva

If your plan's formulary shows that Kariva is not covered, or if the copay is too high, you have two main options: request a coverage exception, or switch to a different Part D plan.

A coverage exception (also called a formulary exception) is a formal request to your plan asking them to cover a drug that is not on the formulary, or to waive a restriction like prior authorization or step therapy. Your doctor must submit this request and explain why Kariva is medically necessary for you — for example, if you have tried other birth control pills and had side effects, or if Kariva is the only option that works for your medical situation. The plan must respond within 72 hours for urgent requests or 7 calendar days for standard requests. Many exceptions are approved, especially if your doctor provides clear medical reasons.

If the exception is denied or you want more options, you can switch to a different Part D plan during the annual open enrollment period (October 15 to December 7). You can compare plans on Medicare.gov to see which ones cover Kariva and what the copay would be. You can also switch if you have a may have access to life event — for example, if you move to a new state or lose other health coverage.

Generic Alternatives to Kariva

Kariva is a brand-name birth control pill. Generic versions containing the same hormones (norgestimate and ethinyl estradiol) are available and are usually cheaper. Your plan may cover the generic version even if it does not cover the brand-name Kariva, or may charge a lower copay for the generic.

Common generic alternatives include Ortho Cyclen, Previfem, and Sprintec. These contain identical active ingredients to Kariva and work the same way. The main difference is usually the price. Ask your doctor or pharmacist whether a generic version would work for you, and ask your plan whether it covers the generic at a lower cost.

Costs and Copays

If your plan covers Kariva, your copay depends on which tier your plan places it on. Most Medicare Part D plans have four or five tiers, with tier 1 (generic drugs) being the cheapest and higher tiers costing more. Brand-name drugs like Kariva are usually on tier 3 or 4. Your copay might range from $15 to $50 or more per month, depending on your plan.

Once you reach the coverage gap (the "donut hole"), your costs change. In 2024, the coverage gap begins after you and your plan have spent $5,850 together on covered drugs. In the gap, you pay a higher percentage of the drug cost until you reach catastrophic coverage. The exact amounts change each year. Your plan's member handbook or website will show your specific costs at each stage.

Questions to Ask Your Doctor

Before you fill a Kariva prescription, ask your doctor these questions:

  • Is Kariva the best option for my medical situation, or would a generic birth control pill work just as well?
  • Will you check with my insurance plan to see whether Kariva is covered and whether prior authorization is needed?
  • If my plan does not cover Kariva, will you submit a coverage exception request and explain why Kariva is medically necessary for me?
  • What should I do if the pharmacy tells me my plan will not pay for this prescription?

Frequently Asked Questions

Does Medicare Part A or Part B cover Kariva?

No. Part A covers hospital care and Part B covers doctor visits and outpatient services. Prescription drugs are covered only under Part D. If you do not have Part D, you will pay the full cost of Kariva out of pocket unless you have other prescription drug coverage.

What if I cannot afford the copay for Kariva?

Ask your doctor or pharmacist about patient information programs run by the drug manufacturer. Many pharmaceutical companies offer free or reduced-cost medications to people who meet income requirements. Your pharmacist can help you find and explore for these programs. You can also ask your plan about switching to a cheaper generic birth control option.

Can I appeal if my plan denies a coverage exception for Kariva?

Yes. If your plan denies your coverage exception request, you have the right to appeal. Your plan must tell you how to appeal in the denial letter. You can ask your doctor to provide additional medical information to support your appeal. The appeals process usually takes 7 to 30 days depending on whether it is standard or expedited.

Will switching Part D plans affect my other Medicare coverage?

No. Your Part D plan is separate from your Part A and Part B coverage. Switching Part D plans does not change your hospital or doctor coverage. You can change your Part D plan during open enrollment without affecting any other Medicare benefits.

What happens if I miss the open enrollment important date to switch plans?

If you miss the October 15 to December 7 important date, you generally cannot switch Part D plans until the next year's open enrollment period. However, if you have a may have access to life event — such as moving, losing other coverage, or becoming newly may be able to access for Medicare — you may be able to switch outside of open enrollment. Contact Medicare at 1-800-MEDICARE to ask whether you may have access to.