Medicare's Coverage of Linzess

Medicare Part D covers Linzess (linaclotide), a prescription medication used to treat irritable bowel syndrome with constipation and chronic idiopathic constipation. Whether your specific plan covers it depends on which Part D plan you are enrolled in — each plan maintains its own formulary, the list of drugs it will pay for. Most major Part D plans do include Linzess, but some require you to meet certain conditions before they will cover it, such as trying a different medication first or getting approval from your doctor in advance.

Original Medicare (Part A and Part B) does not cover prescription drugs. If you have Original Medicare and need Linzess, you must enroll in a Part D plan or use another source of coverage. If you are in a Medicare Advantage plan (Part C), that plan may cover Linzess through its built-in drug benefit, though the rules vary by plan.

Key Takeaways

  • Most Medicare Part D plans cover Linzess, but you must check your specific plan's formulary to confirm it is included.
  • Some plans require prior authorization, meaning your doctor must request approval from the insurance company before you fill the prescription.
  • You may face a copay or coinsurance amount that varies by plan and which tier Linzess is placed on.
  • If your plan does not cover Linzess, you can switch to a different Part D plan during the annual open enrollment period or ask your doctor about covered alternatives.

How to Check if Your Plan Covers Linzess

The fastest way to find out is to log into your plan's website or call the customer service number on the back of your insurance card. Have your prescription ready so you can ask the representative directly whether Linzess is covered and what your out-of-pocket cost will be. You can also ask whether prior authorization is required — if it is, your doctor will need to submit a request before the pharmacy can fill your prescription.

If you do not have your plan information handy, you can visit Medicare.gov and use the Plan Finder tool. Enter your zip code and the medications you take, and it will show you which plans in your area cover those drugs and what the costs are. This tool is updated regularly and can help you compare plans if you are thinking about switching.

Prior Authorization and Other Restrictions

Prior authorization means your doctor must contact your insurance company and explain why you need Linzess before the pharmacy will fill it. Some plans require this; others do not. If your plan does require it, the process usually takes a few business days, though it can be faster if your doctor's office submits the request electronically.

Some plans also use step therapy, which means you may need to try and fail on a cheaper medication first before the plan will cover Linzess. If your plan has this requirement and your doctor believes Linzess is the right choice for you, your doctor can request an exception. These exceptions are sometimes granted, especially if you have a medical reason why other drugs would not work for you.

What Linzess Typically Costs Under Medicare Part D

Your out-of-pocket cost depends on which tier your plan places Linzess on and where you are in your coverage year. Most plans place Linzess on a higher tier because it is a brand-name medication, which means your copay or coinsurance will be higher than for generic drugs. Copays for brand-name drugs typically range from $35 to $75 per prescription, though this varies widely by plan.

Once you have paid a certain amount out of pocket for the year — called your deductible — your plan begins to pay its share. As you continue to use medications throughout the year, you move through different coverage stages, and your costs may change. If your costs become very high, you may reach catastrophic coverage, where Medicare pays most of the cost and you pay only a small copay.

Generic versions of linaclotide may become available in the future, which could lower your costs significantly. Check with your pharmacist or plan to see if a generic is available when you fill your prescription.

What to Do if Your Plan Does Not Cover Linzess

If your current plan does not cover Linzess, you have several options. The simplest is to switch to a different Part D plan during the annual open enrollment period, which runs from October 15 to December 7 each year. You can use the Plan Finder tool on Medicare.gov to see which plans in your area do cover Linzess and compare their costs.

If you need Linzess before open enrollment, ask your doctor whether a covered alternative medication might work for you. Your doctor can also submit a coverage exception request to your plan, explaining why Linzess is medically necessary in your case. Some plans will approve exceptions, though there is no may provide.

Another option is to look into patient information programs run by the drug manufacturer. These programs sometimes provide the medication at a reduced cost or free to people who meet income requirements. Your doctor's office or pharmacist can help you find out whether you may have access to.

Medicare Advantage Plans and Linzess Coverage

If you are enrolled in a Medicare Advantage plan (Part C), that plan covers prescription drugs as part of its benefit package. Some Medicare Advantage plans cover Linzess; others do not. The rules are the same as with Part D — you need to check your specific plan's formulary, and prior authorization may be required.

Medicare Advantage plans often have different copays and coinsurance amounts than Part D plans, and some may have lower costs for Linzess. If you are considering switching from Original Medicare to a Medicare Advantage plan, or from one Advantage plan to another, you can compare drug coverage during open enrollment using the Plan Finder tool.

Frequently Asked Questions

Will Medicare cover Linzess if my doctor says I need it?

Medicare Part D will cover Linzess if your plan includes it on its formulary, but coverage is not automatic. Your plan may require prior authorization or step therapy. If your plan does not cover it, your doctor can request an exception, though approval is not may provide.

What if I cannot afford the copay for Linzess?

Talk to your pharmacist or doctor about patient information programs offered by the drug manufacturer. You can also ask your doctor about covered alternatives that might work for your condition. If your costs are very high, you may be may be able to access for the Extra Help program, which assists low-income Medicare beneficiaries with prescription drug costs.

Can I switch Part D plans if my current plan does not cover Linzess?

Yes, during the annual open enrollment period from October 15 to December 7, you can switch to a different Part D plan. You can use Medicare.gov's Plan Finder to see which plans cover Linzess in your area. If you have a may have access to life event, such as losing other coverage, you may be able to switch outside of open enrollment.

Does Original Medicare cover Linzess?

No. Original Medicare (Part A and Part B) does not cover any prescription drugs. You must enroll in a Part D plan or a Medicare Advantage plan to have prescription drug coverage. If you do not have drug coverage, you can enroll during open enrollment or if you have a may have access to event.

What is the difference between a copay and coinsurance for Linzess?

A copay is a fixed dollar amount you pay each time you fill the prescription — for example, $50. Coinsurance is a percentage of the drug's cost that you pay — for example, 25 percent. Your plan documents will tell you which one applies to Linzess and at what amount.