Otezla costs vary based on your Medicare plan and pharmacy

Otezla (apremilast) is a prescription medication for plaque psoriasis, psoriatic arthritis, and behçet's disease. Under Medicare, what you pay depends on which plan you have, which pharmacy you use, and whether you meet your plan's deductible. There is no single Medicare price for Otezla — the drug costs different amounts at different pharmacies, and your share of that cost changes as you move through your plan's coverage stages.

The manufacturer's list price for Otezla is roughly $4,000 to $5,000 per month, but Medicare negotiates lower prices, and your actual out-of-pocket cost is usually much less. What matters most is understanding how your specific plan structures its drug coverage and what you will owe at each stage.

Key Takeaways

  • Your out-of-pocket cost for Otezla depends on your Medicare Part D plan, your pharmacy, and where you are in your plan's coverage year.
  • Most people with Medicare Part D pay a copay or coinsurance for Otezla once they meet their deductible, typically ranging from $35 to $150 per month.
  • Otezla is usually on the formulary (covered drug list) of most Medicare Part D plans, but placement on the formulary affects your cost.
  • The Medicare Extra Help program and manufacturer information programs can lower your costs if your income is below certain thresholds.
  • Comparing plans during open enrollment can save you hundreds of dollars per year on Otezla and other medications.

How Medicare Part D coverage affects your Otezla cost

Medicare Part D is prescription drug coverage, and it works in stages. First, you pay your plan's monthly premium. Then you pay out of pocket until you reach your deductible — most Part D plans have deductibles between $0 and $545 in 2024, though this amount changes yearly. Once you meet your deductible, you enter the initial coverage stage, where you pay a copay or coinsurance (a percentage of the drug's cost) for each prescription.

Otezla is a brand-name drug, and most Medicare Part D plans place it in a higher cost tier — usually tier 3 or tier 4 out of five tiers. This means your copay or coinsurance will be higher than it would be for a generic drug. At tier 3, you might pay 25% to 35% coinsurance; at tier 4, you might pay 40% or more. Since Otezla costs several hundred dollars per month after Medicare's negotiated price, your coinsurance could be $100 to $200 or more per month.

Once your total drug spending reaches a certain amount (called the initial coverage limit, which is $5,850 in 2024), you enter the coverage gap, sometimes called the "donut hole." In the gap, you pay a larger share of the drug cost — currently 25% of the negotiated price. This stage ends once your out-of-pocket spending reaches $7,050 (in 2024), at which point you enter catastrophic coverage and pay only a small copay.

Copay and coinsurance amounts across different plans

The actual dollar amount you pay for Otezla varies by plan. A Medicare Advantage plan (Part C) that includes drug coverage may have different copays than a standalone Part D plan. Some examples of what people report paying include copays of $50 to $150 per month, or coinsurance of 25% to 40% of the negotiated price.

To find your exact cost, you need to check your plan's formulary — the list of covered drugs — and look up Otezla's tier and your copay or coinsurance amount. You can do this on your plan's website, by calling the plan's customer service number, or by using the Medicare Plan Finder tool at Medicare.gov. When you call or search, have your plan name and member ID ready.

Prices also differ by pharmacy. Some pharmacies negotiate lower prices with Medicare, so filling your Otezla prescription at one pharmacy might cost less than at another. It is worth calling ahead to compare prices at your local pharmacies and mail-order options.

Manufacturer information and Extra Help programs

Celgene, the manufacturer of Otezla, runs a patient information program that may lower your cost if you meet income requirements. The program can help cover copays, coinsurance, and deductibles. You can learn more by calling 1-844-OTEZLA-1 or visiting the Otezla website. You will need to provide proof of income and insurance information to see if you may have access to.

The Medicare Extra Help program (also called the Low-Income Subsidy, or LIS) is a federal program that helps people with limited income and resources pay for Medicare Part D coverage. If you may have access to, the program pays your premiums, deductibles, and copays. To be considered, your income must be below 150% of the federal poverty level, and your resources (savings, investments, property other than your home) must be below $8,100 for an individual or $12,150 for a married couple in 2024. You can explore through your local Social Security office, by phone at 1-800-772-1213, or online at ssa.gov.

Comparing plans to find the lowest Otezla cost

During Medicare's annual open enrollment period (October 15 to December 7 each year), you can switch to a different Part D plan or Medicare Advantage plan. Since Otezla's cost varies by plan, comparing plans before you enroll can save you hundreds of dollars per year.

Use the Medicare Plan Finder tool at Medicare.gov. Enter Otezla as one of your medications, and the tool will show you the estimated out-of-pocket cost for that drug under each plan in your area. The tool accounts for your deductible, copays, coinsurance, and coverage gap costs. You can also call 1-800-MEDICARE to speak with a representative who can help you compare plans by phone.

When comparing, look at the total cost for the year, not just the monthly copay. A plan with a higher monthly copay might have a lower deductible or better coverage in the gap, which could save you money overall. Also check whether your doctor and pharmacy are in the plan's network, because out-of-network costs are usually higher.

What to do if Otezla is not on your plan's formulary

Most Medicare Part D plans cover Otezla, but some do not. If your plan does not cover it, you have options. First, ask your doctor whether there is a similar medication covered by your plan that might work for your condition. If Otezla is the right medication for you, you can request a formulary exception — a request to your plan to cover a drug that is not on the formulary.

To request an exception, your doctor submits a form to your plan explaining why Otezla is medically necessary for you. The plan usually responds within 72 hours. If the plan denies the exception, you can appeal. You can also switch to a different Part D plan during open enrollment that does cover Otezla. Keep in mind that if you switch plans, you may lose any prior authorization or exception you already had with your old plan.

Frequently Asked Questions

Does Medicare Part B cover Otezla?

No. Otezla is an oral medication (a pill), so it is covered under Medicare Part D (prescription drug coverage), not Part B. Part B covers injectable and infused drugs given in a doctor's office or hospital. If you do not have Part D coverage, you will pay the full cost of Otezla out of pocket unless you may have access to for Extra Help or a manufacturer information program.

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

Yes, it likely will. Medicare Part D plans vary by state and region, and Otezla's cost tier and copay differ between plans. If you move, use the Medicare Plan Finder tool to compare plans in your new state. You can switch plans outside of open enrollment if you move, so contact your current plan to report your move and ask about your options.

What happens to my Otezla cost when I enter the coverage gap?

In the coverage gap, you pay 25% of the negotiated price for Otezla instead of your usual copay or coinsurance. For a drug that costs $400 per month after negotiation, you would pay about $100 in the gap instead of your normal copay. Once your out-of-pocket spending reaches $7,050 (in 2024), you move to catastrophic coverage and pay only a small copay again.

Can I use a GoodRx coupon or discount card with Medicare?

You cannot use a GoodRx coupon or other discount card at the same time you use your Medicare Part D coverage — you have to choose one or the other. However, it is worth checking the GoodRx price for Otezla and comparing it to your Part D copay. If the GoodRx price is lower, you can pay cash and use the discount instead of your insurance. Keep in mind this does not count toward your deductible or out-of-pocket maximum.

How often does the cost of Otezla change under Medicare?

Otezla's cost can change yearly when Medicare updates its negotiated prices and when plans change their formularies and cost tiers. Your plan's deductible, copays, and coverage limits also change each January 1. Review your plan's coverage information every October during open enrollment to see if your costs have changed and whether switching plans would save you money.