Does Medicare Cover Statin Prescriptions?

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Two major concerns for many Medicare beneficiaries are whether their drugs will be covered and how much they will cost. Employer drug coverage can be more cost-effective than drug coverage with Medicare, depending on the drugs you take. Therefore, once you start Medicare, the price could be pretty shocking.

Prescription costs might be a major factor while you compare supplement plans, Advantage plans, and Part D plans. If you take a statin drug, you might be wondering how Medicare covers it as you search for the most cost-effective plans for your needs.

What is a statin drug?

Statin drugs are lipid-lowering prescriptions and are also known as HMG-CoA reductase inhibitors. They help people with high cholesterol and those at risk of cardiovascular disease. These lipid-lowering drugs are meant to lower your cholesterol level and reduce the risk of cardiovascular diseases such as heart attacks and strokes.

What are common statin drugs?

There are seven statin drugs approved in the U.S. The generic names are:

  • Atorvastatin
  • Fluvastatin
  • Lovastatin
  • Pravastatin
  • Rosuvastatin
  • Simvastatin
  • Pitavastatin

How do statin prescriptions work?

If your provider orders blood work and the results show that you have high cholesterol, they may consider prescribing you a statin. When there are high levels of cholesterol in your blood, it will ultimately increase your risk of heart attacks and strokes. Cholesterol is a natural substance your body produces, but too high of levels can lead to adverse health conditions.

Your liver produces most of the cholesterol in your body. When you take a Statin drug, the statin blocks a particular enzyme that your liver needs to produce cholesterol. Therefore, your liver will remove the cholesterol from your bloodstream and, overall, lower your cholesterol level.

According to the Mayo Clinic, it is essential to know the common side effects of statins as they could cause muscle pain and damage. Always consult with your provider before starting or stopping taking a specific medication.

Does Original Medicare cover statins?

Original Medicare consists of Part A and Part B. Medicare Part A is your inpatient hospital coverage. It will help cover your costs for your room and board, skilled nursing facility, and home health care after a three-day hospital stay and hospice. Part A may cover some drugs while you’re in the hospital, but generally, that only includes those administered by the healthcare provider.

Part B provides outpatient medical coverage. Part B can also cover drugs administered by a healthcare professional or durable medical equipment. Since statins do not fall into these categories, Original Medicare does not cover them. They will be covered under the plans that provide prescription drug coverage, such as Part D and Medicare Advantage.

How do Part D plans cover statins?

Medicare Part D provides prescription drugs that you get filled at the pharmacy. All Part D plans have a list of covered drugs called the formulary. If the drug is in the plan’s formulary, then the plan provides some coverage. Your cost-sharing all depends on which tier the medication is covered under.

Generally, tiers 1 and 2 cover generic medications and are excluded from the annual deductible. However, it varies with each plan. If the drug falls into the higher tiers, you may need to reach the deductible first before the plan kicks in. After the deductible is satisfied, you’ll have a copay or coinsurance that you must pay when you fill the prescription. The amount of the copay or coinsurance will vary with each plan.

If the plan does not cover the drug, you can file an appeal for a formulary exception.

How do Medicare Advantage plans cover statins?

Most Medicare Advantage plans include drug coverage. If your plan includes drug coverage, it will work the same way as Part D. Therefore, you may need to reach the deductible first before the plan helps with the cost. Additionally, your cost-sharing will vary with each plan.

Summary

Since Medicare Advantage and Part D plans can change their formularies each year, your plan might not cover the drug the following year. You will always want to make sure you are on a plan that covers your prescriptions and is cost-effective.