Medicare's Coverage of Taltz

Medicare Part D (prescription drug coverage) covers Taltz, but whether your plan pays for it depends on your specific plan and whether your doctor's request meets your plan's requirements. Taltz is a biologic medication used to treat psoriasis, psoriatic arthritis, and ankylosing spondylitis. Most Part D plans include it on their formulary — the list of drugs they cover — but many require you to try a less expensive medication first or get written approval from your doctor before they will pay.

Original Medicare (Parts A and B) does not cover Taltz on its own. If you have Original Medicare and want Taltz, you need a Part D plan, a Medicare Advantage plan with drug coverage, or you pay the full cost out of pocket. A single month's supply of Taltz can cost $5,000 to $7,000 without insurance, so coverage matters significantly.

Key Takeaways

  • Most Medicare Part D plans cover Taltz, but your plan may require prior authorization — written approval from your doctor — before paying for it.
  • Many plans require you to try and fail on a cheaper biologic drug first, a step called step therapy, before they will cover Taltz.
  • Your out-of-pocket cost depends on which tier your plan places Taltz on; specialty biologics are usually on the highest tier with the largest copay.
  • You can call your plan's customer service number (on your insurance card) to find out whether Taltz is covered and what your copay would be.
  • If your plan denies coverage, your doctor can appeal the decision or request an exception based on medical need.

How Prior Authorization Works for Taltz

Prior authorization means your doctor must submit a request to your insurance plan before you fill the prescription. The plan reviews your medical history and diagnosis to decide whether to approve it. This process typically takes 24 to 72 hours, though it can be faster if your doctor's office marks it urgent. Your pharmacy will tell you if prior authorization is needed when you try to fill the prescription.

Your doctor's office usually handles the paperwork, but you should call them to confirm they have submitted the request. If you need Taltz urgently and the authorization is delayed, ask your doctor to call the plan directly — many plans have a phone line for urgent requests. Some plans also offer temporary supplies (a 7 or 14-day fill) while authorization is pending.

Step Therapy and Why Plans Use It

Step therapy means your plan will only cover Taltz if you have already tried and not responded to a cheaper biologic drug. Common first-step drugs for psoriasis and psoriatic arthritis include Humira, Enbrel, or Stelara. Your doctor documents that the first drug did not work well enough or caused side effects, then requests coverage for Taltz as the next step.

Step therapy can add weeks or months to getting the medication you need. If your doctor believes you should start on Taltz because of your specific condition or past treatment history, they can request a step therapy exception. This requires them to explain in writing why skipping the cheaper drug is medically necessary. Plans often approve these exceptions, especially if you have already tried similar drugs in the past.

Understanding Your Out-of-Pocket Costs

Your cost for Taltz depends on which tier your Part D plan places it on. Specialty biologic drugs like Taltz are usually on Tier 4 or Tier 5 (the highest tiers), which means you pay a higher percentage of the cost or a higher flat copay. Some plans charge a copay of $150 to $250 per month; others charge 25% to 33% of the drug's cost, which can be $1,000 or more per month depending on the plan.

Once you reach your plan's out-of-pocket maximum (typically $7,050 in 2024, though this changes yearly), Medicare covers 95% of your drug costs for the rest of the year. You can find your plan's exact copay and out-of-pocket maximum on your insurance card or by logging into your plan's website. Call your plan's customer service number if you cannot find this information — they can tell you the exact amount you would pay.

What to Do If Your Plan Denies Coverage

If your plan denies coverage for Taltz, you have the right to appeal. Your doctor can request a coverage information review, which means the plan takes another look at the decision. This is different from an exception request — a review asks the plan to reconsider based on the same information, while an exception asks them to make an exception to their normal rules.

Your doctor can also request an expedited appeal if you need the medication urgently. This speeds up the review from the standard 72 hours to 24 hours or less. If the plan denies the appeal, you can ask for an independent review by someone outside the insurance company. Your plan's denial letter will explain how to request this review and the important date for doing so.

Medicare Advantage Plans and Taltz Coverage

If you have a Medicare Advantage plan (Part C) with drug coverage, Taltz coverage works similarly to Part D. Your plan has its own formulary, prior authorization rules, and step therapy requirements. Some Medicare Advantage plans cover Taltz more readily than others, so if you are shopping for a plan and know you need Taltz, call the plan to ask about their coverage before you enroll.

Medicare Advantage plans often have lower monthly premiums than Original Medicare plus a separate Part D plan, but they may have higher copays for specialty drugs. Compare the total cost — premium plus copay — rather than looking at the premium alone. If you switch to a Medicare Advantage plan during open enrollment, your coverage for Taltz will change on January 1st of the following year.

Questions to Ask Your Doctor and Insurance Plan

Before your doctor prescribes Taltz, ask whether they have already submitted prior authorization to your plan or whether you need to do that first. Ask what your copay will be and whether your plan requires step therapy. If step therapy is required, ask your doctor whether they think you need an exception based on your medical history.

Call your insurance plan's customer service number (on your card) and ask: "Is Taltz on my formulary?" "What tier is it on?" "What is my copay?" and "Does my plan require prior authorization or step therapy?" Write down the date, time, and name of the person you spoke with. If you get different answers later, you can reference this conversation.

Frequently Asked Questions

Can I get Taltz if I have Original Medicare without a Part D plan?

No. Original Medicare does not cover prescription drugs. You must have a Part D plan, a Medicare Advantage plan with drug coverage, or pay the full cost yourself. You can enroll in a standalone Part D plan during the annual open enrollment period (October 15 to December 7) or if you have a may have access to life event.

How long does prior authorization usually take?

Most plans respond within 24 to 72 hours. If your doctor marks the request as urgent, some plans will respond the same day or next business day. Ask your doctor's office to call your plan directly if you need the medication quickly — phone requests often move faster than faxed ones.

What happens if I cannot afford the copay for Taltz?

Taltz's manufacturer offers a copay information program that may reduce your copay to as little as $5 per month if you meet income requirements. Ask your doctor's office or pharmacist for the process, or visit the manufacturer's website. Some community health centers and patient advocacy organizations also offer financial information for biologic medications.

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

Yes, during the annual open enrollment period (October 15 to December 7), you can switch to a different Part D plan or Medicare Advantage plan. Compare plans on Medicare.gov to see which ones cover Taltz and what your copay would be. If you have a may have access to life event (such as moving or losing other coverage), you may be able to switch outside of open enrollment.

What is the difference between an appeal and an exception for Taltz coverage?

An appeal asks your plan to reconsider a denial decision based on the same information. An exception asks your plan to make an exception to their normal coverage rules — for example, to skip step therapy because your doctor believes you need Taltz first. Your doctor can request both, and many plans approve exceptions when the doctor explains the medical reason.