Medicare's Coverage of Relafen DS

Medicare Part D covers Relafen DS (nabumetone), but whether you pay a copay, coinsurance, or the full price depends on which plan you have and which tier the drug sits on. Relafen DS is a nonsteroidal anti-inflammatory drug (NSAID) used for arthritis pain and inflammation. Most plans place it on a standard tier — usually tier 2 or 3 — meaning you will pay a fixed copay or a percentage of the cost after your deductible.

The catch is that not every Part D plan covers it the same way. Some plans may require you to try a cheaper NSAID first (called a step therapy requirement), or they may limit how much they will pay per month. Your actual out-of-pocket cost depends on which specific plan you chose during enrollment and whether you have met your deductible for the year.

If you do not have Part D coverage, or if your plan does not cover Relafen DS at all, you have options: you can switch plans during the annual enrollment period, ask your doctor about generic alternatives, or look into manufacturer discounts.

Key Takeaways

  • Relafen DS is covered by most Medicare Part D plans, but your copay or coinsurance amount varies by plan and tier placement.
  • Some plans require step therapy, meaning you must try a lower-cost NSAID first before the plan will cover Relafen DS.
  • You can check your specific plan's coverage by calling the plan directly, logging into your plan's website, or reviewing your plan's formulary document.
  • If your plan does not cover Relafen DS or the cost is too high, you can switch to a different Part D plan during open enrollment in October through December.
  • Generic nabumetone is usually cheaper than brand-name Relafen DS and is covered by most plans at a lower tier.

How to Check Your Plan's Coverage Before You Fill the Prescription

The fastest way to know what you will pay is to contact your Part D plan directly before your doctor sends the prescription to the pharmacy. Call the customer service number on the back of your insurance card and ask: "Is Relafen DS on my formulary, and what tier is it on?" They will tell you your copay or coinsurance amount and whether any restrictions explore.

You can also log into your plan's website and search the formulary — a list of covered drugs organized by tier. The formulary is public and free to view even if you do not have an account. If you have the plan's name and your state, you can often find the formulary on the plan's website under "Pharmacy" or "Prescriptions."

A third option is to ask the pharmacist. When you pick up the prescription, the pharmacy system will show what your plan covers and what you owe. If the cost is higher than expected, ask the pharmacist whether a generic version or a different NSAID would cost less under your plan.

Step Therapy and Prior Authorization Requirements

Some Part D plans will not pay for Relafen DS unless you have already tried and failed on a cheaper NSAID such as ibuprofen, naproxen, or meloxicam. This is called step therapy. If your plan has this requirement, your doctor will need to document that you tried the other drug first and that it did not work or caused a side effect before the plan will cover Relafen DS.

A few plans also require prior authorization, meaning your doctor must contact the plan and get written approval before the pharmacy can fill the prescription. This usually takes one to three business days. Your doctor's office handles the request, but it is worth asking them to submit it as soon as possible so there is no delay in getting your medication.

If your doctor believes step therapy is not appropriate for your situation — for example, if you have a history of stomach problems with other NSAIDs — they can request an exception. The plan will review the request and may approve coverage without the step therapy requirement.

Generic Nabumetone vs. Brand-Name Relafen DS

Generic nabumetone is the same medication as brand-name Relafen DS and is covered by virtually all Medicare Part D plans. The generic version is almost always placed on a lower tier (usually tier 1 or 2) than the brand name, which means your copay will be lower — often $5 to $15 instead of $25 to $50 or more.

Ask your doctor to prescribe generic nabumetone instead of Relafen DS by name. If your doctor writes "Relafen DS" on the prescription, the pharmacy will dispense the brand name unless you ask them to substitute the generic. Some pharmacies will do this automatically to save you money, but it is safer to request it directly.

If you are already taking Relafen DS and it is working well for you, switching to the generic version should produce the same results — the active ingredient is identical. The only difference is usually the tablet shape, size, or color.

What to Do If Your Plan Does Not Cover Relafen DS

If your current Part D plan does not cover Relafen DS at all, or if the copay is unaffordable, you have three main options. First, ask your doctor about alternative NSAIDs that your plan does cover at a lower cost. Second, look into switching to a different Part D plan during the annual open enrollment period (October 15 through December 7 each year). Third, check whether the manufacturer or a patient information program offers a discount card or copay help.

To switch plans, visit Medicare.gov, call 1-800-MEDICARE, or contact a local State Health Insurance information Program (SHIP). You can compare plans side by side to see which ones cover Relafen DS and at what cost. Keep in mind that switching plans takes effect on January 1 of the following year, so you must act before December 7 to make a change.

Nabumetone Copay Cards and manufacturer programs sometimes reduce your out-of-pocket cost even if your plan covers the drug at a high tier. Search online for "nabumetone copay information" or ask your pharmacist whether any programs are available for your specific situation.

Coverage During the Donut Hole

If you reach the Part D coverage gap (called the "donut hole"), your costs for Relafen DS will change. In 2024, the donut hole begins after you and your plan have spent $5,850 combined on covered drugs. Once you enter the gap, you pay a higher percentage of the drug cost until you reach the catastrophic coverage threshold (usually around $7,050 in out-of-pocket spending).

However, Medicare has been gradually closing the donut hole. In 2024, you pay 25 percent of the cost of most brand-name drugs and generics while in the gap, down from higher percentages in previous years. This means Relafen DS will cost more in the gap than it does before you reach it, but the increase is smaller than it used to be.

To track your spending and know when you are approaching the donut hole, check your online account at Medicare.gov or ask your plan for a spending summary. Some plans send notices when you are close to the gap so you can plan ahead.

Frequently Asked Questions

Will Medicare Part B cover Relafen DS instead of Part D?

No. Part B covers certain drugs administered in a doctor's office or hospital setting, but oral medications like Relafen DS are covered only by Part D. If you do not have Part D coverage, you will pay the full pharmacy price unless you are in a Medicare Advantage plan that includes drug coverage.

What if my doctor prescribes a higher dose of Relafen DS than my plan covers?

Contact your plan and ask whether the higher dose is covered or whether you need prior authorization. If the plan will not cover it, ask your doctor whether a lower dose or a different medication would work. Some plans cover certain doses but not others.

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

You can, but it is usually not allowed to use both at the same time. If the GoodRx price is lower than your Part D copay, you may choose to pay out of pocket with the coupon instead. However, this does not count toward your Part D deductible or out-of-pocket maximum, so it may cost you more in the long run.

Does Medicare cover Relafen DS for conditions other than arthritis?

Medicare Part D covers the drug itself, not the condition. Your doctor decides whether Relafen DS is medically necessary for your situation. If your plan denies coverage because they believe it is not medically necessary, your doctor can request an exception or appeal the decision.