Medicare covers Relafen, but the amount you pay depends on which Medicare plan you have and which pharmacy you use

Relafen (nabumetone) is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain and inflammation from arthritis. Medicare Part D prescription drug plans cover Relafen, but it is not covered under Original Medicare Part B. If you take Original Medicare without a Part D plan, you will pay the full pharmacy price out of pocket. If you are in a Medicare Advantage plan with prescription coverage, Relafen is usually covered, though your out-of-pocket cost depends on your specific plan's formulary — the list of drugs it covers.

The amount you pay for Relafen changes based on which tier your plan places it on. Most plans put Relafen on a higher tier because newer pain medications exist, which means your copay or coinsurance will be higher than it would be for a generic NSAID like ibuprofen or naproxen. You may also pay less if you use a pharmacy in your plan's network.

Key Takeaways

  • Relafen is covered by most Medicare Part D plans and Medicare Advantage plans with drug coverage, but Original Medicare alone does not cover it.
  • Your out-of-pocket cost for Relafen depends on which tier your plan places it on and whether you use an in-network pharmacy.
  • You can check your plan's formulary on your insurance card, your plan's website, or by calling the customer service number on your card.
  • If Relafen is not covered or costs too much, your doctor can request a prior authorization or exception, or you can ask about lower-cost alternatives.
  • Generic nabumetone is usually cheaper than brand-name Relafen and is covered the same way.

How to learn about your plan covers Relafen

The fastest way to know your coverage is to look at your plan's formulary. You can find it three ways: check the back of your insurance card for a website and customer service number, visit your plan's website directly, or call the number on your card and ask a representative to tell you which tier Relafen is on and what your copay will be.

When you call or search online, have your plan name and member ID ready. Ask specifically whether the plan covers Relafen at all, which tier it is on, and what your copay or coinsurance will be. Also ask whether the cost is different at different pharmacies — some plans charge less at mail-order pharmacies or preferred pharmacies.

If you have a Medicare Advantage plan, your coverage may be different from someone else's Medicare Advantage plan, even if you both use the same insurance company. Each plan sets its own formulary, so always check your specific plan rather than assuming based on what a neighbor pays.

What to do if Relafen is not covered or costs too much

If your plan does not cover Relafen or puts it on a tier with a high copay, you have several options. First, ask your doctor whether a generic version of nabumetone is available — it is usually cheaper and covered the same way. If generic nabumetone is also expensive or not covered, ask your doctor about other NSAIDs on your plan's formulary, such as ibuprofen or naproxen, which are often on lower tiers.

Second, your doctor can request a prior authorization or formulary exception from your plan. This is a formal request explaining why you need Relafen specifically rather than a cheaper alternative. If your doctor writes that you have tried other NSAIDs and they did not work, or that you have a medical reason you cannot take them, the plan may approve Relafen at a lower cost or cover it even if it is not on the formulary. This process usually takes three to five business days.

Third, you can ask your pharmacy whether they have a discount program or coupon for Relafen. Some manufacturers offer copay cards that reduce your out-of-pocket cost, though these sometimes do not work with Medicare. Your pharmacist can tell you whether a copay card is available and whether it will work with your plan.

The difference between brand-name Relafen and generic nabumetone

Generic nabumetone is the same medication as brand-name Relafen and works the same way. The main difference is price — generic versions are almost always cheaper. Medicare plans cover both, but they may place them on different tiers. Some plans cover generic nabumetone on a lower tier than brand-name Relafen, which means your copay will be less for the generic.

Ask your doctor or pharmacist whether generic nabumetone will work for you. If your doctor has prescribed brand-name Relafen specifically, you can ask whether switching to generic is safe. In most cases, it is, and your doctor can change the prescription with one phone call to the pharmacy.

Understanding Medicare Part D tiers and how they affect your cost

Medicare Part D plans organize drugs into tiers, usually numbered 1 through 5. Tier 1 drugs (generics) have the lowest copay. Tier 2 drugs (preferred brand-name) cost more. Tier 3 and higher tiers cost even more. Relafen is usually on Tier 3 or Tier 4 because it is a brand-name drug and newer alternatives exist.

Your copay for a Tier 3 or Tier 4 drug might be $35 to $75 per month, depending on your plan. Some plans use coinsurance instead of a copay, which means you pay a percentage of the drug's cost — for example, 25 percent — rather than a flat amount. Check your plan documents or call customer service to find out whether you pay a copay or coinsurance for Relafen.

After you have paid a certain amount out of pocket (called your deductible), your costs may change. Some plans have a coverage gap, sometimes called the "donut hole," where you pay more after you reach a spending threshold. Understanding your plan's structure helps you predict what you will pay over the year.

When to talk to your doctor about Relafen coverage

If you are taking Relafen and your plan's cost is too high, or if you are thinking about starting Relafen, talk to your doctor before filling the prescription. Tell your doctor what your plan covers and what your copay would be. Your doctor may have samples of Relafen to give you while you work out coverage, or may suggest a different NSAID that your plan covers at a lower cost.

If you have tried other NSAIDs and they did not work, or if you have a medical reason you need Relafen specifically, your doctor can document this and request a prior authorization from your plan. Bring your insurance card to the appointment so your doctor's office has your plan information and can submit the request directly.

Frequently Asked Questions

Does Original Medicare Part B cover Relafen?

No. Original Medicare Part B covers hospital and doctor visits, not prescription drugs. You need a Part D plan or a Medicare Advantage plan with drug coverage to have Relafen covered. If you have Original Medicare without Part D, you pay the full pharmacy price.

Can I switch to a different Medicare plan if my current plan does not cover Relafen?

Yes, but only during certain times. You can switch during the Annual Enrollment Period (October 15 to December 7 each year) or if you have a may have access to life event like moving or losing other coverage. Outside these windows, you cannot switch plans. If you need Relafen urgently, ask your doctor about a prior authorization first.

Will my copay for Relafen change if I move to a different state?

Possibly. If you move, you may need to switch to a new Medicare plan because plans are organized by region. Your new plan may cover Relafen on a different tier or at a different copay. Contact your new state's Medicare office or visit Medicare.gov to find plans available in your new location.

What if I cannot afford the copay for Relafen even after a prior authorization?

Ask your doctor about patient information programs run by the drug manufacturer. Some programs offer free or reduced-cost Relafen to people who meet income requirements. Your doctor's office or pharmacist can help you find out whether you may have access to and how to enroll.

Is there a difference in coverage between Medicare Advantage and Medigap plans?

Yes. Medicare Advantage plans include prescription drug coverage as part of the plan, so Relafen coverage depends on your specific Advantage plan's formulary. Medigap plans do not include drug coverage — you need a separate Part D plan. Check your plan documents or call customer service to see how your plan covers Relafen.