Medicare covers Austedo, but only under Part D prescription drug plans, and only after you meet specific requirements

Austedo (deutetrabenazine) is a medication used to treat involuntary movements caused by Huntington's disease and tardive dyskinesia. Medicare Part D plans do cover it, but whether your plan covers it and what you pay depends on your specific plan's formulary — the list of drugs it covers — and where the drug sits on that formulary's tier system.

Original Medicare (Part A and Part B) does not cover Austedo. You must be enrolled in a Part D prescription drug plan, either through a standalone Prescription Drug Plan (PDP) or as part of a Medicare Advantage plan that includes drug coverage, to have any coverage at all.

Key Takeaways

  • Austedo is covered by most Medicare Part D plans, but you must check your specific plan's formulary to confirm it is included.
  • The drug typically falls into a higher cost tier, meaning you will pay a larger share of the cost than you would for generic alternatives.
  • Your plan may require prior authorization from your doctor before it will pay for Austedo, which can delay the first fill by several days.
  • If your plan does not cover Austedo or the cost is too high, you can switch to a different Part D plan during the annual enrollment period or request an exception from your current plan.

How Part D formularies determine what you pay

Each Part D plan creates its own formulary, which groups drugs into tiers. Austedo is not on every formulary, and when it is, it usually sits on Tier 3 or Tier 4 — the higher tiers where you pay a percentage of the cost (called coinsurance) rather than a flat copay. This means your out-of-pocket cost depends on the drug's actual price at the pharmacy, which varies by location and pharmacy.

Some plans may place Austedo on Tier 2 or require it to be a non-preferred brand drug, which also raises your cost. A few plans do not cover it at all. The only way to know your plan's coverage is to check the formulary directly — either on your plan's website, by calling the plan's customer service number on your insurance card, or by using Medicare's Plan Finder tool at Medicare.gov.

If your plan does cover Austedo, you will typically pay somewhere between 25 and 50 percent of the drug's cost, depending on which tier it is on and how much the drug costs at your pharmacy. Once you reach your plan's out-of-pocket spending limit (which varies by plan but was $7,050 in 2024), Medicare and your plan cover the rest.

Prior authorization and other plan requirements

Most Part D plans require prior authorization before they will pay for Austedo. This means your doctor must submit a request to the plan explaining why you need the drug, and the plan must approve it before you fill the prescription. This process usually takes three to five business days, though it can be faster if your doctor's office submits it electronically and follows up.

Some plans also require you to try a different medication first — a requirement called step therapy — before they will cover Austedo. If your plan has this requirement, your doctor will need to document that you have already tried the other drug and it did not work or caused side effects. This can add weeks to the process, so ask your doctor's office to check your plan's requirements before you leave the appointment.

A few plans may also explore quantity limits, meaning they will only cover a certain number of doses per month. If your prescribed dose exceeds that limit, you will have to pay out of pocket for the extra doses or request an exception from the plan.

What to do if your plan does not cover Austedo or the cost is too high

If your current Part D plan does not cover Austedo, does not cover it until you try something else first, or places it on such a high tier that the cost is unaffordable, you have two main options: request an exception from your current plan, or switch to a different plan.

To request an exception, ask your doctor to submit a letter to your plan explaining why Austedo is medically necessary for you and why other covered alternatives are not suitable. The plan must respond within 72 hours (or sooner in urgent cases). If the plan denies the exception, you can appeal the decision, though this takes longer.

If an exception is unlikely to work or you want faster relief, you can switch to a different Part D plan during the annual enrollment period (October 15 to December 7 each year). Use Medicare's Plan Finder to search for plans in your area that cover Austedo on a lower tier. You can also switch if you experience a may have access to life event, such as moving to a new state or losing other drug coverage.

Manufacturer information and other cost-reduction options

Austedo's manufacturer, Teva Pharmaceuticals, offers a copay information program for patients whose insurance covers the drug but whose out-of-pocket costs are high. The program can reduce your copay or coinsurance to as little as $0 per month, depending on your income and insurance. You can learn about this program by calling Teva's patient support line or visiting the Austedo website.

If you do not have Part D coverage at all, or if you are in the coverage gap (the period after you have spent a certain amount on drugs but before catastrophic coverage kicks in), you may also be able to use this copay card to reduce your cost at the pharmacy.

Checking your coverage before you fill the prescription

Before your doctor writes the prescription, call your Part D plan's customer service number and ask three questions: Does your plan cover Austedo? If yes, what tier is it on, and what will your copay or coinsurance be? Does the plan require prior authorization or step therapy?

Write down the answers and the name of the representative you spoke with. If the plan later denies the claim or charges you more than expected, you will have documentation of what you were told. If the plan does require prior authorization, ask your doctor's office to submit the request right away so there is no delay once you are ready to fill the prescription.

Frequently Asked Questions

Does Original Medicare cover Austedo?

No. Original Medicare (Part A and Part B) does not cover any prescription drugs. You must have a Part D plan — either a standalone Prescription Drug Plan or a Medicare Advantage plan with drug coverage — to have coverage for Austedo.

What if I cannot afford the copay even with my Part D plan?

Contact Teva Pharmaceuticals' patient support program to see if you may have access to for copay information. You can also ask your doctor if there are other medications that treat your condition and are covered at a lower cost by your plan. If neither option works, you can request an exception from your plan or switch to a different plan during open enrollment.

Can I use a GoodRx coupon or discount card instead of my Part D plan?

You can, but it is usually not allowed to use both at the same time. If your Part D copay is higher than the GoodRx price, you may be able to pay cash using GoodRx instead, though this means the cost does not count toward your out-of-pocket spending limit. Ask your pharmacist to price both options before you decide.

What happens if my plan denies prior authorization for Austedo?

You can ask your doctor to submit an appeal with additional medical information, or you can request a coverage exception. You also have the right to file a formal appeal with Medicare. If the denial stands, you can switch to a different Part D plan during the next enrollment period or pay out of pocket while you explore other options.

Does my coverage change if I switch from a PDP to a Medicare Advantage plan?

It may. Each Medicare Advantage plan has its own formulary and drug coverage rules, so Austedo might be covered differently — or not at all — under your new plan. Always check the new plan's formulary before you switch to make sure Austedo is covered the way you need it to be.