Unlocking the Benefits: Does Medicare Part D Cover Xarelto?

Are you wondering if your Medicare Part D plan covers Xarelto? Well, you’re in the right place! This article will unlock the benefits and examine whether Medicare Part D pays for Xarelto.

Xarelto is a widely prescribed anticoagulant medication used to prevent blood clots. It is commonly prescribed for conditions such as atrial fibrillation, deep vein thrombosis, and pulmonary embolism. Xarelto is also a very expensive medication. Even with Medicare insurance, the copays are high, especially in the Gap phase of Part D.  

Navigating the intricacies of Medicare coverage can add an additional level of complexity and confusion around prescription drugs.

Medicare Part D is a prescription drug plan offered by private insurance companies approved by Medicare. The program aims to provide affordable access to various medications, but not all drugs are covered. That’s why it’s crucial to understand whether Xarelto is included in the formulary of your specific Part D plan.

I have hundreds of Medicare clients on Xarelto. We run our clients’ medications through our proprietary software to determine the lowest-cost drug plans.  We want the plans to have at least a 3-star or higher Medicare rating. Xarelto is one of many high-dollar medications we have had to deal with for over a decade. This article will delve into Medicare Part D coverage details and explain how we find plans that cover our clients’ Xarelto and other costly medications. So, let’s start unlocking the benefits of Medicare Part D and discovering if Xarelto is covered under your plan.

Understanding Xarelto and Its Importance

Xarelto, also known by its generic name rivaroxaban, is an oral anticoagulant medication that plays a crucial role in preventing blood clots. Blood clots can lead to serious health complications such as stroke, heart attack, or even death. Xarelto works by inhibiting the clotting factors in the blood, reducing the risk of clot formation.

The use of Xarelto is particularly prevalent among individuals with conditions such as atrial fibrillation, deep vein thrombosis, and pulmonary embolism. Atrial fibrillation is an irregular heart rhythm that can increase the risk of blood clots forming in the heart. Deep vein thrombosis occurs when blood clots form in the deep veins of the legs, while pulmonary embolism is a life-threatening condition where a blood clot travels to the lungs.

Given the importance of Xarelto in managing these conditions, individuals must have access to affordable medication. This is where Medicare Part D comes into play, offering coverage for prescription drugs to Medicare beneficiaries. Let’s explore the coverage options under Medicare Part D and how they relate to Xarelto.

Coverage Options Under Medicare Part D

Medicare Part D provides coverage for prescription drugs through private insurance companies that contract with Medicare. There are 21 Medicare Part D plans in the Omaha, Lincoln, and Council metro areas. These plans are designed to offer affordable access to a wide range of medications, including Xarelto. As of the writing of this article (January 2024), all 21 Medicare Part D plans pay for Xarelto. However, it’s important to note that not all Part D plans cover every prescription drug.

Each Medicare Part D plan has a formulary, which is a list of covered drugs. The formulary is divided into different tiers, each with a different cost-sharing structure. Xarelto may be included in the formulary, but its placement within the tiers can affect how much you must pay out of your pocket.

Typically, Part D plans place drugs in different tiers based on their cost and how they compare to other medications in terms of safety and effectiveness. The lower the tier, the lower your out-of-pocket costs will be. It’s worth noting that the formulary and tier structure can vary between different Part D plans, so reviewing your plan’s specific details is essential to determine if Xarelto is covered and at what cost.

How to Determine if Xarelto is Covered Under Your Medicare Part D Plan

You have a few options to determine if Xarelto is covered under your specific Medicare Part D plan. The first step is to review the plan’s formulary. You can usually find this information on the plan’s website or request a copy of the formulary from the insurance company.

When reviewing the formulary, look for Xarelto or its generic equivalent, rivaroxaban. Note the tier in which it is placed and the associated cost-sharing requirements. Remember that formularies can change from year to year, so reviewing the most up-to-date information is essential.

Another helpful resource is the Medicare Plan Finder tool the Centers for Medicare & Medicaid Services (CMS) provides. This online tool allows you to enter your zip code, current medications, and dosage information to compare different Part D plans in your area. The tool will provide a list of plans and estimated costs.  You will learn whether Xarelto is covered and the monthly costs.

If you prefer a more personalized approach, contact the insurance company directly and speak with a representative. They can provide detailed information about your plan’s coverage for Xarelto, including any prior authorization requirements or restrictions.

We Can Help Unlock Your Part B Benefits

Like Medicare, Omaha Insurance Solutions uses a plan finder tool that reviews all the Part D plans, formularies, and prices. The tool shows the various plans, the drug tiers, the medication cost before the Gap (Donut Hole) and in the Gap (Donut Hole), and the total overall cost combining copays and premiums together. You will have a total annual cost for each plan, so you can compare.  We also point out the plan’s Medicare star rating. 

We can filter the Part D information in many ways so you can look at the data as it applies to you. Our service is free when you are a client. We do this every year during the Annual Election Period for our clients to ensure they are on the best plan for their medication needs and budget.    

Researching and understanding your plan’s coverage for all your medications, including Xarelto, can help you make informed decisions about your healthcare and potentially save you money. But what should you do if your Part D plan does not cover Xarelto? Let’s explore the steps you can take in such a situation.

Steps to take if your plan does not cover Xarelto

If your Medicare Part D plan does not cover Xarelto, don’t panic. You can take several steps to explore alternative options and potentially lower your out-of-pocket costs.

1. Speak with your healthcare provider: Your healthcare provider can help you explore alternative medications covered by your plan or suggest other strategies to manage your condition effectively.

2. Request a formulary exception: Sometimes, your healthcare provider can submit a request to the insurance company for a formulary exception. This request outlines why Xarelto is medically necessary for you and provides supporting documentation. If the exception is approved, the insurance company may cover Xarelto, even if it’s not on the formulary.

3. Consider therapeutic alternatives: Your Part D plan may cover alternative medications within the same class as Xarelto. These medications work similarly to Xarelto and may be suitable for your condition. Your healthcare provider can guide you in exploring these alternatives.

4. Explore patient assistance programs: Pharmaceutical companies often offer patient assistance programs that provide financial assistance or free medication to individuals who meet specific eligibility criteria. Due to its high cost, these programs can be a valuable resource if you need help to afford Xarelto.

5. Review other Part D plans: If Xarelto is essential for your health and well-being, consider switching to a different one during the annual enrollment period, typically from October 15th to December 7th each year. By reviewing other plans, you may find one that covers Xarelto or offers more favorable coverage for your specific needs.

Remember, it’s crucial to consult with your healthcare provider and insurance company before changing your medication regimen or coverage. They can provide personalized guidance based on your specific health condition and insurance coverage.

Alternative options for accessing Xarelto at a lower cost

If Xarelto is not covered by your Medicare Part D plan or the out-of-pocket costs are prohibitively high, alternative options are available to access Xarelto at a lower cost.

1. Generic alternatives: Generic versions of Xarelto, known as rivaroxaban, may be cheaper. Generic drugs contain the same active ingredients as their brand-name counterparts and are approved by the FDA as safe and effective. Speak with your healthcare provider and pharmacist to explore whether a generic alternative suits you.

2. Manufacturer discounts and coupons: The pharmaceutical manufacturer may offer discounts or coupons that can help reduce the cost of the medication. These savings programs are often available for eligible individuals who meet specific criteria. Check the manufacturer’s website or discuss these programs with your healthcare provider.

3. Medication assistance programs: Non-profit organizations and foundations may offer medication assistance programs that provide financial support or free medication to individuals in need. These programs often have specific eligibility criteria, so it’s important to research and understand the requirements before applying.

4. Pharmacy discount programs: Some pharmacies, including Xarelto, offer discount programs or savings cards to help lower prescription medication costs. These programs may provide discounts for individuals paying out-of-pocket or even those with insurance coverage.

It’s worth noting that while these alternative options can help reduce the cost of Xarelto, it’s important to discuss them with your healthcare provider and consider their recommendations. They can provide valuable insights based on your specific health condition and medication needs.

Tips for Maximizing your Medicare Part D coverage for Xarelto

To maximize your Medicare Part D coverage for Xarelto, consider the following tips:

1. Review your plan annually: Medicare Part D plans can change their formularies and coverage yearly. Take the time to review your plan’s coverage during the annual enrollment period with your agent to ensure Xarelto is still covered and assess any potential changes in cost-sharing requirements. From October 15th to December 7th, we work around the clock to ensure our clients’ medications are covered in their Part D or Medicare Advantage plan within their budget.   

2. Consider the total cost: When evaluating different Part D plans, Don’t solely focus on the monthly premium- this is a very common mistake. Consider the deductible, copayments, and coinsurance, as these factors can significantly impact your out-of-pocket costs for Xarelto.  

Total Annual Cost! Not just copays, or t just monthly premiums. Not just the cost outside the donut hole. It is the total annual cost you pay. 

3. Utilize preferred pharmacies: Some Part D plans have preferred pharmacy networks to access medications at lower copayments. Check if your plan has a preferred pharmacy network, and consider utilizing these pharmacies to reduce your medication costs. I have had clients save hundreds and 

4. Explore mail-order options: Mail-order pharmacies often offer discounted prices for prescription medications, including Xarelto. If your plan allows for mail-order prescriptions, it may be worth considering this option to save on your medication costs.

By staying proactive and informed, you can maximize your Medicare Part D coverage and ensure affordable access to Xarelto.

Common Misconceptions about Medicare Part D Coverage for Xarelto

There are several common misconceptions about Medicare Part D coverage for Xarelto that are important to address:

1. All Part D plans cover Xarelto: Not all Part D plans cover Xarelto, and its coverage can vary depending on the plan. Review your specific plan’s formulary to determine if Xarelto is covered and at what cost is essential.

2. Coverage is the same across all Part D plans: Xarelto’s coverage and cost-sharing requirements can vary between different Part D plans. It’s crucial to compare the formularies and associated costs of various plans to find one that suits your needs.

3. Once covered, Xarelto will always be covered: Formularies can change annually, and a medication covered in the past may not be covered in the future. Reviewing your plan’s formulary annually during the annual enrollment period is vital to ensure Xarelto is still covered.  

This Medicare mistake is the bane of my existence. Some clients do not take the annual review period seriously. They do not send us an updated list of medications. They do not talk with us, and when January comes—and it is too late—they call because a particular medication is not covered or the cost is significantly higher than the previous year.  

4. Generic alternatives are always covered: While generic alternatives are often less expensive, they may not be covered by all Part D plans. Reviewing your plan’s formulary is crucial to determine if the generic version of Xarelto is covered.

By dispelling these misconceptions, you can approach your Medicare Part D coverage for Xarelto with a clear understanding of what to expect and how to navigate the system’s complexities.

Resources and Assistance Programs for Xarelto Users

If you need assistance accessing Xarelto or managing the cost of the medication, several resources and assistance programs can provide support:

1. Extra Help/Low-Income Subsidy: The Extra Help program is a federal program that helps individuals with limited income and resources pay for their Medicare prescription drug costs. Eligible individuals can receive assistance with premiums, deductibles, and copayments. To determine if you qualify for Extra Help, contact the Social Security Administration or visit their website.

2. Patient Assistance Programs (PAPs): Pharmaceutical manufacturers often offer patient assistance programs that provide free or low-cost medications to individuals who meet specific eligibility criteria. These programs can be a valuable resource for individuals who cannot afford their medications, including Xarelto. Check the manufacturer’s website or discuss these programs with your healthcare provider.

3. State Pharmaceutical Assistance Programs (SPAPs): Some states have their own pharmaceutical assistance programs that provide financial assistance or low-cost medications to eligible individuals. These programs may have specific eligibility criteria and income limits, so it’s important to research the programs available in your state. Nebraska and Iowa do not have these types of programs. 

4. Non-profit organizations and foundations: Various non-profit organizations and foundations provide financial assistance or free medication programs for individuals in need. These programs often have specific eligibility criteria and may focus on particular medical conditions. Research and reach out to relevant organizations to explore potential assistance options.

By leveraging these resources and programs, you can access the support you need to afford Xarelto and manage your health effectively.

Conclusion: Making Informed Decisions about Medicare Part D Coverage for Xarelto

Understanding the complexities of Medicare Part D coverage for Xarelto is essential for individuals who rely on this medication to manage their health conditions effectively. By delving into the details of coverage

options, determining if Xarelto is covered by your specific plan, exploring alternative options, and maximizing your Part D coverage, you can make informed decisions about your healthcare.

Remember to consult with your healthcare provider and insurance agent professional throughout the process to ensure you make decisions that align with your specific health needs. By staying proactive and informed, you can unlock the benefits of Medicare Part D and access the necessary medications, such as Xarelto, at an affordable cost.  Give us a call at Omaha Insurance Solutions at 402-614-3389, and we will help unlock the benefits of Medicare Part D for you.