Medicare's coverage of rimantadine depends on which part of your plan you have and where you fill the prescription
Rimantadine is an antiviral medication used to treat or prevent influenza A. Medicare Part D (prescription drug coverage) covers rimantadine, but the specifics — including whether you pay a copay, coinsurance, or the full cost — depend on your individual plan's formulary, which is the list of drugs your plan covers.
Not every Part D plan covers rimantadine the same way. Some plans may require you to pay a higher copay, ask your doctor to try a different antiviral first (called a prior authorization), or limit how many doses you can receive in a year. Original Medicare (Parts A and B) does not cover outpatient prescription drugs at all, which is why Part D exists.
If you are enrolled in a Medicare Advantage plan (Part C), that plan includes prescription drug coverage built in, and rimantadine coverage works the same way — it depends on that specific plan's formulary.
Key Takeaways
- Rimantadine is covered under Medicare Part D prescription drug plans, but your out-of-pocket cost depends on your plan's formulary and your current coverage stage.
- You should check your plan's formulary before your doctor prescribes rimantadine to understand what you will pay and whether prior authorization is required.
- If rimantadine is not covered or costs too much under your plan, your doctor may be able to prescribe a different antiviral that your plan covers at a lower cost.
- Your plan's coverage of rimantadine may change from year to year, so it is worth reviewing during annual enrollment even if you have used it before.
How to check if your specific plan covers rimantadine
The fastest way to find out what rimantadine will cost you is to look at your plan's formulary online. You can access this through your plan's website or by calling the customer service number on your insurance card. Have your plan name and member ID ready.
When you contact your plan or search the formulary, ask three things: (1) Is rimantadine on the formulary? (2) What tier is it on, and what will my copay or coinsurance be? (3) Does my doctor need to get prior authorization before prescribing it? These answers will tell you exactly what to expect at the pharmacy.
If you do not have your plan information handy, you can also call Medicare directly at 1-800-MEDICARE (1-800-633-4227). They can tell you which plans in your area cover rimantadine and help you compare costs.
What happens if rimantadine is not on your plan's formulary
If your plan does not cover rimantadine, you have several options. The first is to ask your doctor whether an alternative antiviral would work for your situation. Oseltamivir (Tamiflu) and zanamivir (Relenza) are other antivirals used for influenza, and they may be covered at a lower cost under your plan.
You can also request a formulary exception from your plan. This is a formal request asking your plan to cover a drug that is not on the formulary, usually because your doctor believes it is medically necessary for you. Your doctor will need to submit this request, and the plan will make a decision within a set timeframe — typically a few days for urgent requests and up to 72 hours for standard ones.
If your plan denies the exception and you believe the decision is wrong, you have the right to appeal. Your doctor can help with this process by providing additional medical information to support why rimantadine is the right choice for you.
Understanding your costs at different coverage stages
Medicare Part D divides the year into coverage stages, and your out-of-pocket costs change as you move through them. When you first fill a prescription, you are in the deductible stage — you may pay the full cost of rimantadine until you reach your plan's deductible amount (which varies by plan).
Once you meet your deductible, you enter the initial coverage stage, where you pay a copay or coinsurance for each prescription. This is usually the stage where most people fill prescriptions during the year.
If your total drug costs reach a certain amount (called the initial coverage limit, which changes yearly), you enter the coverage gap, sometimes called the "donut hole." In this stage, you pay a higher percentage of the cost. However, once your out-of-pocket spending reaches the catastrophic threshold, your plan covers most of the cost for the rest of the year.
Prior authorization and step therapy requirements
Some Medicare Part D plans require prior authorization before they will cover rimantadine. This means your doctor must contact your plan and get approval before writing the prescription. This usually takes one to two business days, though urgent requests can be faster.
Other plans use step therapy, which means you may need to try a different antiviral first and show that it did not work before the plan will cover rimantadine. Step therapy can delay treatment, so if your doctor believes rimantadine is the right first choice for you, ask them to request an exception to step therapy when they submit the prior authorization.
Your doctor's office handles these requests — you do not need to contact the plan yourself, though you can follow up to make sure the request was sent and to check on its status.
What to do if rimantadine is too expensive
If your plan covers rimantadine but the cost is higher than you expected, talk to your doctor or pharmacist about lower-cost alternatives. Some antivirals are available as generics, which cost less than brand-name versions. Your pharmacist can tell you whether a generic version of rimantadine or another antiviral is available.
You can also ask your plan whether the drug is available at a lower tier if you use a specific pharmacy — some plans offer better prices at preferred pharmacies. Comparing prices between pharmacies can also save money; prices for the same medication vary widely, and your plan's customer service can tell you which pharmacies in your area have the lowest cost for rimantadine.
If cost is still a barrier, ask your doctor whether there are patient information programs run by the drug manufacturer. These programs sometimes provide medication at reduced cost or free to people who meet income requirements.
Rimantadine coverage during open enrollment
Medicare Part D formularies change every year, which means rimantadine's coverage status, tier, and copay can be different in the new year. During the annual open enrollment period (October 15 to December 7), you should review your current plan's coverage of any medications you take regularly, including rimantadine.
If your plan is raising the copay for rimantadine or removing it from the formulary, you may want to switch to a different plan that covers it at a lower cost. You can compare plans on Medicare.gov or by calling 1-800-MEDICARE. Switching plans takes effect January 1 of the following year.
Frequently Asked Questions
Does Original Medicare cover rimantadine?
No. Original Medicare (Parts A and B) does not cover outpatient prescription drugs. You need Part D coverage to have rimantadine covered. If you have Original Medicare and no Part D plan, you can enroll during the annual open enrollment period or within 63 days of losing other drug coverage.
Will my Medicare Advantage plan cover rimantadine?
Medicare Advantage plans (Part C) include prescription drug coverage, so rimantadine is covered under those plans. However, coverage varies by plan, so you should check your specific plan's formulary the same way you would with a standalone Part D plan.
What if my doctor prescribes rimantadine but my plan requires prior authorization?
Your doctor's office will submit the prior authorization request to your plan before you fill the prescription. This usually takes one to two business days. If it is urgent, ask your doctor to request expedited review. You should not fill the prescription until the plan approves it, or you may have to pay the full cost out of pocket.
Can I get rimantadine if I am in the coverage gap?
Yes, but you will pay a higher percentage of the cost while you are in the coverage gap. Once your out-of-pocket spending reaches the catastrophic threshold, your plan covers most of the cost for the rest of the year. Ask your plan what you will pay at each stage so you can plan ahead.
Is there a generic version of rimantadine that costs less?
Yes, rimantadine is available as a generic medication, which is usually less expensive than a brand-name version. Ask your pharmacist whether the generic is available and what your copay would be. Your plan may also cover the generic at a lower tier than the brand name.