Medicare's Coverage of Rexulti

Medicare Part D covers Rexulti (brexpiprazole), but whether your specific plan pays for it depends on which plan you're in and what tier the drug sits on. Rexulti is a prescription antipsychotic used to treat major depressive disorder and schizophrenia. Most standard Part D plans include it, though you may pay a copay or coinsurance, and some plans require prior authorization before the pharmacy will fill it.

The amount you pay out of pocket varies. If Rexulti is on your plan's formulary (the list of covered drugs), you'll typically pay a copay at the pharmacy — often $10 to $50 per month depending on the tier. If it's not on the formulary, you can ask your plan to cover it anyway, but the plan may deny the request or ask your doctor to try a different drug first.

Medicare Part A and Part B do not cover Rexulti. Only Part D prescription drug plans cover it. If you have Original Medicare without a Part D plan, you have no prescription coverage through Medicare for this drug.

Key Takeaways

  • Rexulti is covered by most Medicare Part D plans, but your out-of-pocket cost depends on which plan you're in and what tier the drug is assigned to.
  • You will likely pay a copay of $10 to $50 per month, though some plans may require coinsurance (a percentage of the cost) instead.
  • Your plan may require prior authorization from your doctor before the pharmacy fills the prescription, which can delay your first dose by a few days.
  • If Rexulti is not on your plan's formulary, you can ask your doctor to request a coverage exception, though the plan may ask you to try a cheaper alternative first.

How to Find Out What Your Plan Covers

The fastest way to know your exact cost is to call the customer service number on the back of your Medicare card. Have your plan name and member ID ready. Tell them you want to know the copay for Rexulti and whether prior authorization is required. They can answer both questions in one call.

You can also check your plan's formulary online. Log into your plan's website or call and ask them to mail you the formulary. Search for "brexpiprazole" (the generic name) or "Rexulti" and note what tier it's on. Tier 1 drugs are usually cheapest; Tier 4 or 5 drugs cost more.

If you're still in the Medicare open enrollment period (October 15 to December 7 each year), you can switch to a different Part D plan that may have a lower copay for Rexulti. Use the Medicare Plan Finder tool at Medicare.gov to compare plans side by side.

Prior Authorization and Step Therapy

Some Part D plans require your doctor to get prior authorization before the pharmacy will fill Rexulti. This means your doctor must contact the plan and explain why you need this specific drug. The plan usually responds within 24 to 72 hours.

A few plans use step therapy, which means the plan asks your doctor to try a cheaper antipsychotic first. If that drug doesn't work or causes side effects, the plan will then cover Rexulti. If your doctor believes step therapy is medically inappropriate for you, they can request an exception. This process takes longer — usually one to two weeks — so talk to your doctor early if you know you need Rexulti.

What to Do If Your Plan Doesn't Cover Rexulti

If Rexulti is not on your plan's formulary, ask your doctor to submit a coverage exception request. Your doctor writes a letter explaining why you specifically need Rexulti and why alternatives won't work. The plan has 72 hours to respond (or longer if it's an urgent request).

If the plan denies the exception, you have the right to appeal. Your doctor can appeal on your behalf, or you can contact your plan's appeals department directly. Keep copies of all letters and notes about your condition and why other drugs didn't work.

Another option is to ask your doctor about patient information programs run by the drug manufacturer. Otsuka Pharmaceutical, which makes Rexulti, offers copay cards and other programs that can reduce your cost. Your doctor's office or the pharmacy can help you find and enroll in these programs.

Costs During Different Medicare Stages

Your out-of-pocket cost for Rexulti changes depending on where you are in the Medicare Part D benefit year (January 1 to December 31). In the deductible stage, you pay the full price until you've spent your plan's deductible amount (usually $545 to $565 in 2024, though this changes each year). After that, you enter the initial coverage stage and pay only a copay or coinsurance.

If your total drug costs reach the coverage gap threshold (around $5,850 in 2024), you enter the "donut hole." In the gap, you pay a higher percentage of the drug cost — currently 25 percent of the price. Once your out-of-pocket spending reaches the catastrophic threshold (around $7,050 in 2024), Medicare pays most of the cost and you pay only a small copay.

These dollar amounts change every year. Check your plan's summary of benefits or call customer service to find out the exact thresholds for your plan year.

Generic and Brand-Name Options

Rexulti does not have a generic version yet. The brand-name drug is what's available, so all Part D plans cover the same medication — the difference is only in the copay and prior authorization rules.

Your doctor may suggest older antipsychotics like aripiprazole (Abilify) or quetiapine (Seroquel) as alternatives. These drugs have generic versions and are usually cheaper. If your plan's copay for Rexulti is high, it's worth asking your doctor whether a generic antipsychotic might work for you, though only your doctor can make that decision based on your medical history.

Frequently Asked Questions

Will Medicare cover Rexulti if I have a Medigap plan?

Medigap plans do not cover prescription drugs. You still need a separate Part D plan to cover Rexulti. If you have Original Medicare plus a Medigap plan, you must enroll in a Part D plan during the initial enrollment period or during open enrollment to get prescription coverage.

What if I can't afford the copay for Rexulti?

Ask your pharmacy about copay information programs. Otsuka Pharmaceutical offers copay cards that can reduce your cost to as little as $5 per month. Your doctor's office or the pharmacy can help you find and enroll. You may also may have access to for the Medicare Extra Help program if your income is low enough.

Can I get Rexulti through a Medicare Advantage plan instead of Part D?

Medicare Advantage (Part C) plans include prescription drug coverage as part of the plan. Some Advantage plans cover Rexulti; others don't. You'll need to check your specific plan's formulary the same way you would with a standalone Part D plan.

How long does prior authorization take?

Most plans respond to prior authorization requests within 24 to 72 hours. Your doctor's office submits the request, and the plan contacts them with approval or denial. Ask your doctor to submit it as soon as possible so you don't have to wait for your first dose.

Does Medicare cover Rexulti for off-label uses?

Medicare Part D covers Rexulti only for the uses approved by the FDA: major depressive disorder and schizophrenia. If your doctor prescribes it for another condition, the plan may deny coverage. Talk to your doctor and plan about whether coverage is likely before starting treatment.