Medicare covers Trulicity, but the amount you pay depends on which Medicare plan you have and whether you meet your plan's requirements

Trulicity (dulaglutide) is an injectable medication for type 2 diabetes. Medicare Part D, which covers prescription drugs, includes Trulicity on most formularies — the list of drugs your plan will pay for. However, "covered" does not mean free. You will likely pay a copay or coinsurance, and your plan may require you to try other diabetes medications first or meet a deductible before coverage begins.

If you have Original Medicare (Part A and B only, with no Part D plan), Trulicity is not covered. You would need to purchase a Part D plan during the annual enrollment period, or pay the full price out of pocket. If you have a Medicare Advantage plan (Part C), that plan includes drug coverage, and Trulicity may be covered under its formulary.

The cost you actually pay depends on three things: which Part D plan you chose, whether your plan requires prior authorization or step therapy, and which coverage stage you are in during the year.

Key Takeaways

  • Medicare Part D covers Trulicity on most plans, but you pay a copay or coinsurance after meeting your deductible.
  • Your specific Part D plan determines the exact cost, and some plans require you to try cheaper diabetes drugs first.
  • If you have Original Medicare without Part D, Trulicity is not covered unless you add a Part D plan.
  • You can call your plan's customer service number (on your insurance card) to find out your exact out-of-pocket cost before filling the prescription.

How Part D coverage works for Trulicity

Part D plans organize drugs into tiers, usually four or five levels. Trulicity is typically placed on Tier 3 or Tier 4, which means it costs more than generic drugs but may cost less than specialty drugs. Your copay or coinsurance for Tier 3 or 4 drugs is higher than for Tier 1 generics — often $35 to $75 per month or more, depending on your plan.

Before your plan pays anything, you must meet your annual deductible. Most Part D plans have a deductible between $0 and $505 (the exact amount varies by plan and year). Once you meet the deductible, you enter the initial coverage stage, where you pay your copay or coinsurance and your plan pays the rest.

If your total drug costs reach a certain threshold during the year, you may enter the coverage gap (sometimes called the "donut hole"). In the gap, you pay a higher percentage of the drug cost. However, Medicare has been closing this gap over time, and many plans now offer gap coverage for insulin and other diabetes drugs.

Step therapy and prior authorization requirements

Many Part D plans do not pay for Trulicity right away. Instead, they use step therapy, which means your doctor must first prescribe and document that you tried a cheaper drug (usually metformin or another oral medication) and it did not work well enough. Only then will the plan cover Trulicity.

Some plans also require prior authorization, meaning your doctor must contact the plan and get written approval before the pharmacy can fill the prescription. This can add a few days to the process. Your doctor's office usually handles this step, but you should ask them to confirm they have submitted the request.

If your plan denies coverage because of step therapy or prior authorization, you have the right to appeal. Your doctor can also request an exception if they believe Trulicity is medically necessary despite the plan's requirements.

Finding your exact cost before you fill the prescription

The only way to know what you will pay is to contact your Part D plan directly. Call the customer service number on the back of your insurance card and ask: "What is my copay for Trulicity?" or "What will I pay out of pocket for dulaglutide?" Have your plan name and member ID ready.

You can also use the plan's website or call your pharmacy and ask them to run the prescription through your insurance to see the cost. Many pharmacies can tell you the price before you pick up the medication.

If the cost is higher than you expected, ask your doctor whether a different diabetes medication might be covered at a lower tier, or whether your plan offers a patient information program. Many drug manufacturers, including Eli Lilly (which makes Trulicity), offer copay cards or free medication programs for people who cannot afford their drugs.

What to do if you do not have Part D coverage

If you have Original Medicare and no Part D plan, you can add one during the annual enrollment period (October 15 to December 7 each year). You can also add a plan if you experience a may have access to life event, such as loss of other drug coverage. Outside these windows, you cannot enroll in Part D until the next annual period, unless you may have access to for a special enrollment period.

If you need Trulicity now and cannot wait for enrollment, you have a few options. You can pay the full retail price (which varies by pharmacy, but is often $300 to $400 per month for a one-pen pack). You can ask your doctor for a generic alternative that may be cheaper. You can also contact the manufacturer's patient information program to see whether you may have access to for free or reduced-cost medication.

If you have a Medicare Advantage plan, drug coverage is included, and you should check your plan's formulary to see whether Trulicity is covered and what your cost will be.

Medicare Advantage plans and Trulicity

Medicare Advantage (Part C) plans combine hospital, medical, and drug coverage in one plan. Most Medicare Advantage plans include Part D drug coverage, so Trulicity is usually covered. However, the formulary and your out-of-pocket cost may differ from Original Medicare Part D plans.

To find out whether your Medicare Advantage plan covers Trulicity, check the plan's formulary (available on the plan's website or by calling customer service) or call your plan directly. The process for prior authorization and step therapy is the same as with Part D plans.

Copay information and manufacturer programs

If your Part D copay for Trulicity is too high, Eli Lilly 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. You can find this card on the Trulicity website or ask your doctor's office for one.

Eli Lilly also runs a patient information program for people without insurance or with high out-of-pocket costs. You can call 1-800-545-5979 or visit the Trulicity website to learn whether you may have access to. These programs are free and do not count against your Medicare benefits.

Frequently Asked Questions

Does Medicare Part B cover Trulicity?

No. Part B covers some injectable medications, but only those given in a doctor's office or hospital. Trulicity is self-injected at home, so it falls under Part D (prescription drug coverage) instead. You must have a Part D plan for Medicare to help pay for it.

What if my doctor says I need Trulicity but my plan says I have to try a different drug first?

Your doctor can request an exception to the step therapy requirement by contacting your plan and explaining why Trulicity is medically necessary for you. This is called a formulary exception or coverage exception. If the plan denies the exception, you can appeal the decision.

Will my Trulicity cost change if I move to a different state?

Yes. Part D plans are offered by private insurance companies and vary by state and region. If you move, you can change your Part D plan during the annual enrollment period or within 60 days of moving. Your new plan may have a different formulary and different copays for Trulicity.

Can I use a GoodRx coupon instead of my Medicare Part D plan?

You can, but it is usually not a good idea. If you use a discount coupon instead of your insurance, that cost does not count toward your deductible or out-of-pocket maximum. This can leave you paying more overall. Compare the GoodRx price to your Part D copay before deciding.

What happens to my Trulicity coverage if I switch from Original Medicare to a Medicare Advantage plan?

Most Medicare Advantage plans cover Trulicity, but the copay and formulary requirements may be different. Check your new plan's formulary before the switch takes effect, and contact your doctor's office to make sure there are no gaps in your prescription refills during the transition.