What Medicare covers for Repatha depends on your plan and medical history
Repatha (evolocumab) is a PCSK9 inhibitor — a newer type of cholesterol-lowering injection that works differently from statins. Medicare Part D (prescription drug coverage) does cover Repatha, but not automatically for everyone. Your coverage depends on which Part D plan you have, whether your doctor thinks you need it, and whether you have tried other cholesterol drugs first.
Most Part D plans require you to start with a statin or other standard cholesterol medication before they will pay for Repatha. This is called a step therapy or prior authorization requirement. Your doctor will need to document that you have tried those drugs and either they did not work well enough or you cannot tolerate them because of side effects.
If you have Original Medicare (Part A and B only, with no Part D plan), you do not have prescription drug coverage through Medicare itself. You would need to buy a separate Part D plan, use a Medicare Advantage plan that includes drug coverage, or pay out of pocket.
Key Takeaways
- Medicare Part D covers Repatha, but most plans require you to try standard cholesterol drugs first and get your doctor's approval.
- Your specific coverage rules are in your plan's formulary — a list you can request from your insurance company or find on their website.
- Your doctor will need to submit a prior authorization request explaining why you need Repatha instead of other options.
- If your Part D plan denies coverage, you can ask your doctor to appeal or request an exception on your behalf.
- The out-of-pocket cost varies by plan and by which tier Repatha is placed on, ranging from copays to coinsurance percentages.
How to check your own Part D plan's coverage
Your Part D plan publishes a document called a formulary that lists every drug the plan covers and what you pay for it. Repatha appears on most formularies, but the rules around when it is covered are different for each plan. You can find your plan's formulary in three ways: call the customer service number on your insurance card, visit your plan's website and search for "formulary" or "drug list", or call 1-800-MEDICARE and ask them to mail you a copy.
When you look at the formulary, search for "evolocumab" (the generic name) or "Repatha" (the brand name). The entry will tell you which tier it is on — usually Tier 3, 4, or 5, meaning higher out-of-pocket costs. It will also note if there are restrictions, such as "prior authorization required" or "step therapy applies." Step therapy means your doctor must show that you tried a cheaper drug first.
If the formulary is hard to read or you cannot find Repatha listed, call your plan directly. Ask: "Is Repatha covered? What tier is it on? Do I need prior authorization? What do I pay?" Write down the answers and the date you called.
What your doctor needs to do to get coverage approved
Your doctor does not automatically know whether your insurance will pay for Repatha. Before prescribing it, they should contact your Part D plan to request prior authorization — formal approval from the insurance company. Your doctor's office will submit your medical records, cholesterol test results, and a letter explaining why you need Repatha instead of a standard statin or other first-line drug.
The insurance company usually responds within 3 to 5 business days. If they approve it, your pharmacy can fill the prescription. If they deny it, your doctor can appeal the decision or request an exception — asking the plan to cover it anyway based on your specific medical situation. This appeal process can take another 1 to 2 weeks.
Tell your doctor's office that you want them to handle the prior authorization before you leave the appointment. Do not wait until you try to fill the prescription at the pharmacy, because that delays everything. If your doctor's office says they do not do prior authorizations, ask to speak with the office manager or find a different doctor who will advocate for you.
What you will pay out of pocket
Repatha is an expensive drug — the list price is several thousand dollars per month. Your actual cost depends on which tier your plan places it on and how much of your deductible you have already met. Most Part D plans put Repatha on Tier 4 or 5, meaning you pay either a flat copay (often $50 to $150 per injection) or a percentage of the cost called coinsurance (often 25% to 33%).
Once you reach your plan's out-of-pocket maximum for the year, Medicare covers the rest of Repatha at no cost to you. The out-of-pocket maximum for Part D in 2024 is $7,050, but this varies by year. If the monthly cost is too high, ask your doctor or pharmacist whether the drug manufacturer offers a patient information program — many do, and they can reduce or eliminate your copay if your income is below a certain level.
Repatha is given as an injection under the skin, usually once every two weeks or once a month depending on the dose. Your pharmacy may mail it to you, or you may pick it up in person. Some plans cover home delivery at no extra charge; others charge a small fee.
What to do if your plan denies coverage
If your Part D plan says no to Repatha, you have the right to appeal. Your doctor can submit an appeal letter with new information about why you specifically need this drug — for example, if you had a heart attack despite being on a statin, or if the statin caused muscle pain that prevented you from taking it. The plan must respond to an appeal within 72 hours for urgent cases or 7 days for standard cases.
You can also ask your doctor to request a formulary exception, which is a one-time approval to cover a drug that is not on the plan's list or has restrictions. Formulary exceptions are granted when the plan agrees that the standard drugs will not work for you. Your doctor writes a letter explaining your medical situation, and the plan decides within 72 hours to 7 days.
If the appeal and exception both fail, you have one more option: you can switch to a different Part D plan during the annual open enrollment period (October 15 to December 7 each year) and choose a plan that covers Repatha with fewer restrictions. You can also contact your State Health Insurance information Program (SHIP) — a free counselor who can help you understand your rights and next steps. Call 1-800-MEDICARE to find your state's SHIP.
Repatha versus other cholesterol drugs Medicare covers
Repatha is one of several newer cholesterol drugs available. Medicare Part D also covers statins (like atorvastatin and rosuvastatin), which are usually Tier 1 or 2 and cost much less. It covers ezetimibe (Zetia), which blocks cholesterol absorption and is also low-cost. It covers other PCSK9 inhibitors like Praluent (alirocumab) and Leqvio (inclisiran), which work similarly to Repatha but may have different coverage rules on your specific plan.
Your doctor will recommend Repatha or another PCSK9 inhibitor if your cholesterol remains high despite taking a statin, or if you cannot tolerate statins. PCSK9 inhibitors lower LDL cholesterol more aggressively than statins alone. They are injected rather than taken as pills, which some people prefer and others find inconvenient. Ask your doctor which drug is most likely to work for your cholesterol numbers and which one your insurance is most likely to cover.
When to contact Medicare or your plan directly
Contact your Part D plan if you have questions about your specific coverage, your copay amount, or whether prior authorization is needed. You can call the number on your insurance card, and most plans have customer service available 8 a.m. to 8 p.m. seven days a week. Have your member ID number ready.
Contact 1-800-MEDICARE (1-800-633-4227) if your plan is not answering your questions, if you want to file a complaint about a coverage denial, or if you need help finding a plan that covers Repatha. Medicare counselors can also tell you whether you are may be able to access to switch plans outside the normal enrollment period if your current plan denies a drug your doctor prescribed.
Contact your doctor's office if you have been on Repatha and your plan suddenly stops covering it, or if your copay increases dramatically. Your doctor may be able to appeal on your behalf or help you find a lower-cost alternative that works as well.
Frequently Asked Questions
Does Original Medicare Part B cover Repatha?
No. Part B covers doctor visits and hospital care, not prescription drugs. Repatha is a prescription drug, so only Part D covers it. If you have Original Medicare without a Part D plan, you need to buy a separate Part D plan or a Medicare Advantage plan that includes drug coverage.
Can I get Repatha without prior authorization?
It depends on your plan. Some plans cover Repatha without prior authorization if your doctor prescribes it, but most require it. Check your formulary or call your plan to find out. Even if prior authorization is not required, your plan may still deny it if you have not tried a statin first.
What if I cannot afford the copay for Repatha?
Ask your pharmacist or doctor whether the manufacturer (Amgen) offers a patient information program. Many drug makers reduce or eliminate copays for people with low incomes. You can also ask your doctor about switching to a less expensive cholesterol drug that your plan covers with a lower copay.
Will my coverage for Repatha change next year?
Yes, it may. Part D plans change their formularies every year, and Repatha might move to a different tier, require new restrictions, or be removed entirely. Review your plan's new formulary every October during open enrollment to see if you need to switch plans.
Can I appeal if my plan says I have to try a statin first?
Yes. If you have already tried a statin and it did not work or caused side effects, your doctor can appeal and provide that evidence. The plan must consider your appeal and respond within 7 days. If the appeal fails, you can request a formulary exception based on your medical history.