Medicare Does Cover Repatha, But With Conditions

Medicare Part D covers Repatha (evolocumab), a prescription drug that lowers cholesterol, but you will pay a share of the cost through your plan's formulary structure. The drug is not automatically covered at the same price by every Part D plan — coverage depends on which plan you chose during enrollment, what tier the plan places Repatha on, and whether your doctor's request meets the plan's prior authorization requirements.

Repatha is a PCSK9 inhibitor, a newer class of cholesterol medication. Because it is expensive — the list price is several thousand dollars per month — Medicare Part D plans treat it as a specialty drug, which means higher out-of-pocket costs than common medications. Your actual cost will depend on your specific plan's design and your total drug spending for the year.

Key Takeaways

  • Repatha is covered by Medicare Part D, but most plans require your doctor to submit a prior authorization request before the pharmacy will fill it.
  • The drug appears on the specialty tier of most Part D plans, meaning you will pay a percentage of the cost (often 25 to 33 percent) rather than a flat copay.
  • Your plan must have Repatha on its formulary list; not all Part D plans cover it, so you should check your plan documents or call the plan directly.
  • Once you reach the catastrophic coverage phase of Part D, Medicare pays most of the cost, but specialty drugs still require you to pay a small percentage.

How Part D Plans Cover Repatha

Part D plans organize drugs into tiers, and Repatha sits on the specialty tier because of its cost and complexity. Tier 1 drugs (generics) have the lowest copay; Tier 2 (preferred brand-name drugs) cost more; Tier 3 (non-preferred brand-name drugs) cost even more; and Tier 4 or 5 (specialty drugs) have the highest cost-sharing. Repatha is almost always a Tier 4 or Tier 5 drug, which means you pay a percentage of the drug's cost rather than a fixed amount.

The percentage you pay depends on your plan. Many plans charge 25 to 33 percent coinsurance for specialty drugs, though some charge as much as 50 percent. This means if Repatha costs $5,000 per month, you might pay $1,250 to $2,500 out of pocket, depending on your plan's structure. The exact amount is listed in your plan's formulary document, which you can request from your plan or view online.

Not every Part D plan covers Repatha. Some plans exclude it entirely or cover only certain PCSK9 inhibitors (such as Praluent or Biltiveri). Before you enroll in a plan or assume your current plan covers Repatha, you must check the plan's formulary. You can do this by logging into your plan's website, calling the plan's customer service number, or using Medicare.gov's Plan Finder tool.

Prior Authorization and Your Doctor's Role

Most Medicare Part D plans require prior authorization before they will cover Repatha. This means your doctor must submit a request to the plan explaining why you need the drug, and the plan must approve it before the pharmacy can fill your prescription. Prior authorization typically takes three to five business days, though it can take longer if the plan requests additional information from your doctor.

Your doctor's request must show that you meet the plan's criteria for coverage. Plans usually require evidence that you have high cholesterol that has not responded to statins alone, or that you cannot tolerate statins. Some plans also require that you have tried a generic PCSK9 inhibitor first, or that you have heart disease or a family history of early heart disease. The exact requirements vary by plan.

If the plan denies the prior authorization request, your doctor can appeal the decision or request an exception. This process can add weeks to the timeline. To avoid delays, ask your doctor's office to contact your plan before writing the prescription, so you know whether the plan will cover it and what documentation you need to provide.

What Repatha Costs at Different Stages of Part D

Your out-of-pocket cost for Repatha changes as you move through the different phases of Part D coverage. In the initial coverage phase (after you have paid your deductible), you pay your coinsurance percentage. Once your total drug spending reaches the coverage gap threshold — $5,850 in 2024, though this amount changes yearly — you enter the coverage gap, sometimes called the "donut hole."

In the coverage gap, you pay a higher percentage of the cost. For brand-name drugs like Repatha, you pay 25 percent of the cost in 2024, and the plan pays 5 percent. Generic drugs have different cost-sharing in the gap. This phase ends when your total out-of-pocket spending reaches the catastrophic threshold, which is $7,050 in 2024.

Once you reach catastrophic coverage, Medicare pays most of the cost of Repatha, and you pay only a small coinsurance amount (5 percent in 2024). If you use Repatha regularly, you may reach catastrophic coverage by mid-year, which significantly reduces your costs for the rest of the year. You can estimate your costs using Medicare's online calculator or by calling your plan directly.

Comparing Repatha to Other Cholesterol Medications

Repatha is one of three PCSK9 inhibitors covered by Medicare: the others are Praluent (aflibercept) and Biltiveri (inclisiran). All three are specialty drugs with similar cost-sharing structures. Some plans cover all three; others cover only one or two. If your plan does not cover Repatha, it may cover Praluent or Biltiveri at a lower cost, or your doctor may be able to request an exception.

Before Repatha, the standard treatment for high cholesterol was statins (such as atorvastatin or rosuvastatin), which are much cheaper and covered at lower tiers. If you have not tried a statin, or if you tolerate statins well but your cholesterol is still too high, your doctor may recommend adding Repatha. However, many plans require proof that you have tried statins first before they will cover Repatha.

Inclisiran (Biltiveri) is a newer option that works differently — it is given as an injection twice a year rather than a monthly injection. Some people find this more convenient, and some plans may cover it with lower cost-sharing. Ask your doctor whether inclisiran might be an option for you, and check whether your plan covers it.

Steps to Take Before Your Doctor Prescribes Repatha

Before your doctor writes a prescription, contact your Part D plan to confirm that Repatha is on the formulary and to understand your cost-sharing. You can find your plan's phone number on your Medicare card or at Medicare.gov. When you call, ask: Is Repatha covered? What tier is it on? What is my coinsurance percentage? Does the plan require prior authorization? What documentation does the plan need from my doctor?

Once you have this information, share it with your doctor's office. Ask the office to submit the prior authorization request if the plan requires one, and ask them to include any documentation the plan needs. If the plan denies the request, ask your doctor whether an appeal or exception request is appropriate, or whether a different medication might work.

If your current plan does not cover Repatha, you have options. You can switch to a different Part D plan during the annual enrollment period (October 15 to December 7 each year), or you can ask your doctor about alternative medications that your plan does cover. If you have Medicare Advantage with prescription drug coverage, the rules are similar but the specific formularies and prior authorization requirements differ by plan.

Frequently Asked Questions

Does Medicare Part B cover Repatha instead of Part D?

No. Repatha is a self-injected drug that you administer at home, so it is covered under Part D (prescription drugs) rather than Part B (drugs administered in a doctor's office). If you were to receive Repatha as an infusion in a hospital or clinic, Part B might cover it, but this is not the standard way the drug is given.

What if I cannot afford my coinsurance for Repatha?

Contact your plan to ask about copay information programs or patient information programs run by the manufacturer. Amgen, which makes Repatha, offers a copay card that can reduce your out-of-pocket cost to as little as $0 per month, depending on your insurance and income. Your doctor's office or pharmacist can help you find and enroll in these programs.

Can I switch Part D plans to get better coverage of Repatha?

Yes, during the annual enrollment period (October 15 to December 7), you can switch to a different Part D plan. Use Medicare.gov's Plan Finder to compare plans and see which ones cover Repatha and at what cost. If you are already taking Repatha, switching plans mid-year is not usually possible unless you have a may have access to life event.

Will my cost for Repatha change next year?

Yes. Part D plans change their formularies and cost-sharing every year, and the coverage gap and catastrophic thresholds change annually. During the annual enrollment period, review your plan's new formulary to confirm Repatha is still covered and to see whether your coinsurance percentage has changed.

What if my doctor prescribes a different PCSK9 inhibitor because my plan does not cover Repatha?

That is a reasonable alternative. Praluent and Biltiveri work similarly to Repatha and may be covered by your plan with better cost-sharing. Ask your doctor which option your plan covers and what the costs would be. If none of the PCSK9 inhibitors are affordable, discuss with your doctor whether other cholesterol medications might help.