Medicare's coverage of metolazone depends on which part of your plan you have and where you fill the prescription

Metolazone is a water pill (diuretic) prescribed to reduce fluid buildup in people with heart failure, kidney disease, or high blood pressure. Medicare Part D covers metolazone at most pharmacies, but you will pay a copay or coinsurance based on your specific plan. If you take it as an inpatient in a hospital, Medicare Part A covers it as part of your hospital stay. The amount you pay depends on which tier your plan places metolazone on and whether you have met your deductible.

Because metolazone is a generic medication that has been available for decades, it is inexpensive to manufacture and is included on nearly every Medicare Part D formulary. This means most people with Medicare can get it covered, though the exact cost varies by plan and by where you fill the prescription.

Key Takeaways

  • Medicare Part D covers metolazone at retail and mail-order pharmacies, but your out-of-pocket cost depends on your plan's formulary tier and your deductible status.
  • If you are hospitalized, Medicare Part A covers metolazone as part of your inpatient hospital benefit, with no separate drug charge.
  • Metolazone is usually placed on a lower formulary tier (Tier 1 or 2), which means your copay is typically $5 to $15 per month.
  • You can check your specific plan's formulary on your insurer's website or by calling the customer service number on your Medicare card.
  • If your plan does not cover metolazone or the cost is too high, you can request a coverage review or switch plans during the annual enrollment period.

How Medicare Part D covers metolazone at the pharmacy

Medicare Part D is the prescription drug coverage that covers metolazone when you fill it at a pharmacy. Your Part D plan maintains a formulary, which is a list of covered drugs organized into tiers. Metolazone is almost always on the formulary because it is a generic medication that has been available for decades and costs very little to manufacture.

The tier your plan places metolazone on determines your copay. Generic drugs like metolazone are usually on Tier 1 or Tier 2, which means you will pay $5 to $15 per month at most pharmacies. Some plans may place it on Tier 3, which would raise your copay to $25 to $50. You can find your plan's specific copay by logging into your plan's website, calling the number on your Medicare card, or asking the pharmacist when you fill the prescription.

Your deductible also affects what you pay. If you have not yet met your Part D deductible for the year, you may have to pay the full cost of metolazone out of pocket until the deductible is satisfied. Once you meet the deductible, you pay only your copay or coinsurance for each refill. Most people reach their deductible within the first few months of the year, so you will likely pay the lower copay for most of your refills.

What happens if you take metolazone in the hospital

If you are admitted to a hospital and metolazone is given to you as an inpatient, Medicare Part A covers it as part of your hospital stay. You do not receive a separate bill for the drug itself. Instead, the hospital bills Medicare Part A for your entire stay, including room, meals, nursing care, and all medications given to you while you are there.

You will pay your Part A hospital deductible (which is $1,676 for 2024, though this amount changes yearly) plus any coinsurance if your stay extends beyond 60 days. The metolazone itself has no additional charge beyond what you already owe for the hospital stay. If you are discharged and need to continue taking metolazone at home, that prescription will be covered under your Part D plan at your regular copay.

Generic metolazone versus brand-name alternatives

Metolazone is available as a generic medication, which is why it costs so little and is covered on almost every Medicare Part D formulary. The brand name Zaroxolyn is also available but is much more expensive and is rarely covered by Medicare Part D plans without a prior authorization request.

If your doctor prescribes Zaroxolyn, your pharmacy will likely tell you that the generic version is covered at a much lower copay. In most cases, the generic and brand-name versions work the same way. If your doctor believes you need the brand-name version specifically, you can ask your plan for a coverage review, though approval is uncommon for a drug where a generic alternative exists. Your doctor would need to document a medical reason why the generic does not work for you.

What to do if your plan does not cover metolazone

It is very rare for a Medicare Part D plan to exclude metolazone entirely, but if yours does, you have options. First, contact your plan and ask whether the drug is on the formulary. If it is not, ask whether you can request a coverage review. Your doctor can submit a letter explaining why metolazone is medically necessary for you, and the plan will decide whether to cover it.

If the coverage review is denied or if your copay is too high, you can switch to a different Medicare Part D plan during the annual enrollment period, which runs from October 15 to December 7 each year. You can compare plans on Medicare.gov to find one that covers metolazone at a lower copay. If you need metolazone before the enrollment period opens, talk to your doctor about whether a different diuretic covered by your plan might work for you temporarily.

How to find your plan's formulary and copay information

The fastest way to find out what you will pay for metolazone is to check your plan's formulary online. Log into your insurer's website (the name is on your Medicare card) and search for metolazone in the drug search tool. The result will show you the tier, copay, and any restrictions like prior authorization.

If you do not have online access or prefer to speak with someone, call the customer service number on the back of your Medicare card. Have your prescription ready so you can tell the representative the dose and quantity your doctor prescribed. They will tell you the exact copay and whether any prior authorization is needed before you fill the prescription.

You can also ask your pharmacist to check your coverage when you bring in the prescription. They can tell you the copay when ready and let you know if there are any issues with your plan's coverage. This takes only a few minutes and saves you from being surprised at the register.

Frequently Asked Questions

Will Medicare cover metolazone if my doctor says it is medically necessary?

Yes. If metolazone is on your plan's formulary, Medicare Part D covers it regardless of the reason your doctor prescribed it. If it is not on the formulary, you can request a coverage review and your doctor can submit a letter of medical necessity, but approval is not may provide.

What if I cannot afford the copay for metolazone?

If your copay is high, ask your pharmacist whether a generic alternative diuretic (like furosemide or hydrochlorothiazide) is covered at a lower copay. You can also look into the Medicare Extra Help program if your income is low enough. Contact your local Area Agency on Aging or call 1-800-MEDICARE for information about financial information programs.

Does Medicare Advantage cover metolazone?

Yes. Medicare Advantage plans (Part C) include prescription drug coverage as part of the plan. Metolazone is almost always covered, but your copay depends on your specific plan's formulary. Check your plan documents or call the plan's customer service number to find your copay.

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

You cannot use both at the same time. You must choose either your Medicare Part D coverage or a discount card like GoodRx. In most cases, your Medicare copay will be lower, but it is worth comparing the price at the pharmacy. Tell the pharmacist you want to compare the Medicare price and the GoodRx price before you decide which to use.

What if metolazone is not available at my pharmacy?

Metolazone is widely available at most chain and independent pharmacies. If your pharmacy does not stock it, ask them to order it — it usually arrives within one to two business days. You can also transfer your prescription to a different pharmacy or use a mail-order pharmacy through your Medicare Part D plan, which often offers lower copays for 90-day supplies.