Medicare Part D covers Repatha, but only under specific conditions

Repatha (evolocumab) is a PCSK9 inhibitor — a drug that lowers LDL cholesterol — and Medicare Part D plans do cover it. However, coverage is not automatic. Your specific plan may require you to try other cholesterol drugs first, pay a higher copay, or get written approval from your doctor before the pharmacy will fill the prescription. The coverage rules depend on which Part D plan you chose and what your plan's formulary says about the drug.

The fastest way to know your coverage is to call the customer service number on the back of your Part D card and ask three things: Is Repatha on your plan's formulary? What tier is it on? Do you need prior authorization? You will get a yes-or-no answer in minutes, and the representative can also tell you what your out-of-pocket cost will be.

Key Takeaways

  • Most Medicare Part D plans cover Repatha, but it is usually placed on a higher tier that requires a larger copay than basic drugs.
  • Your plan may require prior authorization — a written approval from your doctor — before the pharmacy will dispense the medication.
  • Some plans require step therapy, meaning your doctor must document that you tried and did not tolerate other cholesterol drugs first.
  • Call your Part D plan's customer service line to confirm coverage, your copay amount, and any authorization requirements before your doctor writes the prescription.

How Part D formularies determine Repatha coverage

A formulary is the list of drugs your Part D plan will pay for. Each plan creates its own formulary, so coverage varies from plan to plan. Repatha appears on most formularies, but the tier it sits on — usually Tier 3 or Tier 4 — determines how much you pay out of pocket. Tier 1 and Tier 2 drugs have lower copays; Tier 3 and Tier 4 drugs have higher ones.

The tier placement reflects the plan's judgment about the drug's cost and how many alternatives exist. Because Repatha is expensive and other cholesterol drugs are available, plans often place it on a higher tier. This does not mean the plan refuses to cover it; it means you will pay more if you use it. Your Part D plan mails you a formulary booklet each year, or you can view it on the plan's website by logging into your account.

Prior authorization and step therapy requirements

Prior authorization means your doctor must submit a written request to your Part D plan before you can fill the prescription. The plan reviews the request — usually within 24 to 72 hours — and either approves it or denies it. If approved, the pharmacy receives a code that allows them to fill the prescription. If denied, your doctor can appeal or try a different drug.

Step therapy is a related requirement: your plan may insist that you try a cheaper drug first (such as a statin or ezetimibe) and show that it did not work or caused side effects before the plan will cover Repatha. This is common for expensive drugs. Your doctor can request an exception if they believe step therapy is medically inappropriate, but the plan has the final say. Ask your doctor's office to contact your Part D plan directly — they handle these requests routinely and know the fastest path.

What to do if your plan denies coverage

If your Part D plan denies Repatha or requires step therapy you believe is unnecessary, you have options. First, ask your doctor to submit a written appeal explaining why Repatha is medically necessary for you — for example, if you have familial hypercholesterolemia or have had a heart attack despite taking other drugs. Plans must respond to appeals within 72 hours.

If the appeal fails, you can request a coverage information review through Medicare itself. You have 60 days from the denial to ask for this review. Your doctor can help with this process. You can also switch to a different Part D plan during the annual open enrollment period (October 15 to December 7 each year) if your current plan's coverage is not working for you.

Comparing your copay across different Part D plans

If you are considering switching plans, Repatha's copay can vary significantly. One plan might place it on Tier 3 with a $50 copay; another might place it on Tier 4 with a $100 copay. The Medicare Plan Finder tool on Medicare.gov lets you enter Repatha and see which plans in your area cover it and at what cost. You can compare plans side by side and see the total estimated cost for the year based on your prescriptions.

Keep in mind that switching plans also means changing which pharmacies are in your network and which other drugs are covered at what tier. If you take multiple medications, compare the total cost across all your drugs, not just Repatha. Some plans offer lower copays on Repatha but higher copays on other drugs you need.

What happens after your Part D plan approves Repatha

Once your plan approves the prescription, you pick it up at a pharmacy in your plan's network. Repatha is a self-injected medication that comes as a pre-filled pen or syringe. Your doctor or a nurse will show you how to inject it — the process takes a few minutes. You inject it under the skin, usually once every two weeks or once a month, depending on the dose your doctor prescribes.

Your pharmacy will fill the prescription for a 30-day or 90-day supply, depending on your plan and the pharmacy's policies. You pay your copay at the counter. After you reach your deductible and your plan's coverage gap (if your plan has one), your costs may change — this is part of how Part D cost-sharing works across the year.

Frequently Asked Questions

Does Medicare Part B cover Repatha instead of Part D?

No. Repatha is a self-injected drug you use at home, so it falls under Part D (prescription drugs), not Part B (doctor-administered drugs). Part B covers drugs given in a doctor's office or hospital. If your doctor were to inject Repatha for you in the office, Part B might cover it, but that is not how Repatha is typically used.

What if I cannot afford the copay even after my plan approves it?

Repatha's manufacturer, Amgen, offers a copay information program that can reduce your out-of-pocket cost to as little as $0 per month, depending on your income and insurance. Ask your doctor's office or pharmacist for the Repatha support program phone number, or visit the Repatha website. You will need to provide proof of income and insurance information to enroll.

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

You can, but it is usually not allowed to combine a discount card with Part D coverage in the same transaction. You would have to choose one or the other. In most cases, your Part D copay will be lower than a GoodRx price, especially if your plan covers Repatha. Ask your pharmacist to price it both ways before you decide.

Will my coverage change if I switch from Original Medicare to a Medicare Advantage plan?

Yes. Medicare Advantage plans include prescription drug coverage (Part D) built in, and each plan has its own formulary. Some Advantage plans may cover Repatha more generously than others. If you are considering switching to Advantage, use the Medicare Plan Finder to check Repatha coverage under the plans available in your area.

How often do Part D formularies change?

Part D plans can change their formularies once per year, effective January 1. Plans must notify you of major changes by October 15 of the prior year. If your plan removes Repatha from its formulary or moves it to a higher tier, you will have the right to switch plans during the annual open enrollment period without penalty.