Does Medicare Cover Repatha? 

Cholesterol has long been known as a contributing factor when it comes to cardiovascular disease. In fact, low-density lipoprotein, the so-called bad cholesterol, is a risk factor for heart attacks and strokes. The body naturally produces cholesterol and needs it to function properly, but cholesterol must be balanced in order to maintain optimum health. Seniors often face health concerns related to high cholesterol, and health concerns can be exacerbated when high cholesterol is combined with high blood pressure.

If someone has high cholesterol, the blood pathways of the arteries can become blocked. A buildup of cholesterol in the arteries narrows these pathways and can starve the heart and brain of oxygenated red blood cells. To treat high cholesterol, changes to diet and exercise are often enough for most seniors. Statin medications designed to lower cholesterol can be used as well. When these measures aren’t enough, your doctor may prescribe a medication like Repatha.

What is Repatha?

Repatha (evolocumab) is a prescription medication that helps your body to clear more bad cholesterol. Unlike statins which reduce the amount of cholesterol produced in the liver, Repatha works to clear cholesterol from the liver. It does this by acting upon certain proteins responsible for cholesterol processing. With regular use under a doctor’s supervision, it is believed that Repatha can provide support for seniors who have tried statins but are still experiencing high cholesterol.

Does Medicare cover Repatha?

Medicare insurance covers prescription medications through Medicare Part D. In order for a medication to qualify for Part D coverage, it must be listed in your plan’s formulary. This list covers all of the medications your Part D coverage pays for. It also provides specific information related to limitations and restrictions for individual drugs. Each plan has its own formulary, so Medicare recipients are encouraged to consult this list to learn about their specific coverage.

If your Part D plan covers Repatha, your Medicare benefits won’t fully apply toward the cost of the medication until you have met your plan’s Part D deductible. This amount can vary by plan, and some people will need to meet an additional deductible threshold set by Medicare. Medicare Part D deductibles can vary based on income, but no deductible can be higher than $505 in 2023.

You may also need to pay a copay amount when picking up your prescription from your local pharmacy. This amount can once again vary based on your plan and plan limitations. Medicare Part D prescription drug plans usually require a monthly premium to be paid in order to keep Medicare coverage active. This amount varies by plan, and in most cases, plans that cover more drugs come with higher prices.

How Medicare covers Repatha in inpatient and outpatient settings

Although Repatha is meant to be taken at home according to your doctor’s instructions, it is possible that Medicare recipients may be administered Repatha in an inpatient or outpatient setting. When this takes place, Medicare Parts A and B apply instead of Medicare Part D.

In an outpatient setting like a medical clinic or diagnostic testing laboratory, Repatha is covered by Medicare Part B. This part of Medicare coverage has its own deductible to meet, and a separate premium applies. In an inpatient setting like a Medicare-participating hospital or skilled nursing facility, Repatha is covered by Medicare Part A. This is time-limited coverage that applies to all medications provided as part of an inpatient admittance

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