Medicare does cover Repatha, but only under specific conditions

Medicare Part D (prescription drug coverage) covers Repatha, a medication that lowers cholesterol, but your out-of-pocket cost depends on your plan and which tier the drug sits on. Most plans place Repatha on a higher tier because it is expensive — typically $14,000 to $16,000 per year before insurance. You will pay a percentage of the cost (coinsurance) rather than a flat copay once you reach the coverage gap, and you may need prior authorization from your plan before your pharmacy will fill it.

Medicare Part B does not cover Repatha as an injection you give yourself at home. Part B covers drugs administered in a doctor's office or hospital, so if your doctor injects Repatha during an office visit, that would fall under Part B instead — but most people using Repatha inject it themselves, which means Part D is your coverage route.

Key Takeaways

  • Repatha is covered by Medicare Part D, but your plan must include it on its formulary and you may need prior authorization before filling the prescription.
  • Repatha typically sits on a higher cost tier, meaning you pay coinsurance (a percentage of the drug cost) rather than a fixed copay, especially after you enter the coverage gap.
  • The actual amount you pay depends on your specific Part D plan, which formulary tier Repatha is on, and where you are in the yearly deductible and coverage gap.
  • If your plan does not cover Repatha or the cost is too high, you can switch to a different Part D plan during the annual enrollment period or ask your doctor about generic alternatives or patient information programs.

How Part D coverage works for Repatha

Part D plans assign drugs to formulary tiers, usually numbered 1 through 5. Tier 1 and 2 drugs (generics and preferred brand-name drugs) have the lowest copays. Repatha almost always lands on Tier 3, 4, or 5 because it is a specialty drug — meaning you pay coinsurance instead of a copay. Coinsurance is a percentage of the drug's cost: if your plan sets coinsurance at 25 percent and Repatha costs $1,000 per dose, you pay $250.

Your Part D plan also has a yearly deductible (the amount you pay before the plan starts sharing costs), an initial coverage phase (where you pay coinsurance), a coverage gap (where you pay more), and catastrophic coverage (where your costs cap out). Once you hit the catastrophic phase, Medicare pays most of the cost and your out-of-pocket spending stops climbing. Because Repatha is expensive, you may reach catastrophic coverage faster than with other drugs.

Before your pharmacy fills a Repatha prescription, your plan usually requires prior authorization — a check that the drug is medically necessary for your condition. Your doctor's office normally handles this step, but it can add one to three days to the process. If your plan denies the request, your doctor can appeal or ask the plan to cover a different cholesterol drug instead.

What you pay depends on your specific plan

Medicare Part D plans vary widely. Some plans cover Repatha with a $50 to $100 coinsurance per injection; others charge 25 to 33 percent of the drug cost. A few plans do not cover Repatha at all. The only way to know your exact cost is to check your plan's formulary (the official list of covered drugs) or call your plan's customer service number, which is on your insurance card.

If you are in Original Medicare (Part A and B only) without a Part D plan, you have no prescription drug coverage and would pay the full retail price of Repatha out of pocket. You can join a Part D plan during the annual enrollment period (October 15 to December 7 each year) or within 63 days of losing other drug coverage.

Prior authorization and what your doctor needs to do

Most Part D plans require prior authorization for Repatha because of its cost. Your doctor's office submits a form to your insurance plan showing your cholesterol levels, which other drugs you have tried, and why Repatha is the right choice. The plan usually responds within 24 to 72 hours.

If the plan denies prior authorization, your doctor can request a peer-to-peer review, where a doctor at the insurance company speaks directly with your doctor about your case. This step often overturns a denial. Your doctor can also ask the plan which cholesterol drugs are covered without prior authorization and whether switching to one of those would work for you.

Switching plans if Repatha costs too much

If your current Part D plan charges too much for Repatha or does not cover it, you can switch to a different plan during the annual enrollment period. Compare plans using Medicare's Plan Finder tool at Medicare.gov — enter Repatha and your pharmacy to see the exact copay or coinsurance each plan charges. Plans change their formularies every year, so a plan that did not cover Repatha last year might cover it this year, or vice versa.

If you are already in a plan and Repatha's coverage changes mid-year in a way that harms you, you may be able to switch plans outside the enrollment period. Contact your plan to ask whether a coverage change qualifies you for a special enrollment period.

Patient information programs and manufacturer discounts

Repatha's manufacturer, Amgen, runs a patient information program that can reduce your out-of-pocket cost if you meet income limits. The program covers copays and coinsurance for people with Medicare, Medicaid, or no insurance. You can learn about it by calling Amgen at 1-844-REPATHA (1-844-737-2842) or visiting the Repatha website.

Some pharmacies also offer discount programs or coupons that stack on top of your insurance, lowering your final cost. Ask your pharmacy whether they have a discount program for Repatha before you fill the prescription.

Frequently Asked Questions

Will my doctor's office handle the prior authorization, or do I have to do it?

Your doctor's office almost always handles prior authorization. When you get a Repatha prescription, tell the pharmacy you have Medicare Part D and let them know your plan name. The pharmacy will contact your plan and your doctor's office to request authorization. You do not need to do anything unless the plan denies the request and your doctor asks you to provide additional medical records.

What if my Part D plan does not cover Repatha at all?

You can switch to a different Part D plan during the annual enrollment period (October 15 to December 7). Use Medicare's Plan Finder to compare plans and see which ones cover Repatha and at what cost. You can also ask your doctor whether a different cholesterol drug that your plan does cover would work for your condition.

Does Medicare Part B ever cover Repatha?

Part B covers Repatha only if a doctor injects it in an office or hospital setting. Most people using Repatha inject it themselves at home, which means Part D covers it instead. If your doctor wants to give you Repatha injections in the office, ask whether that would be covered under Part B and what your cost would be.

Can I use a manufacturer coupon along with my Medicare Part D coverage?

No. Federal law prohibits using manufacturer coupons with Medicare Part D. However, Amgen's patient information program is separate from coupons and can reduce your cost if you meet income requirements. Call 1-844-REPATHA to learn whether you may have access to.

What happens to my Repatha cost once I reach the catastrophic phase?

Once you hit catastrophic coverage, you pay only 5 percent coinsurance on Repatha for the rest of the year, and Medicare pays the other 95 percent. Because Repatha is expensive, you may reach catastrophic coverage within a few months, which significantly lowers your yearly out-of-pocket cost.