Immunosuppressants are drugs that you take following a transplant to prevent your body from rejecting the donor organ. The way Medicare covers your immunosuppressant medication depends on the circumstances of your transplant.
Part B covers your immunosuppressants if you meet all of the following requirements:
- You received your transplant in a Medicare-approved facility
- You had Medicare Part A at the time of your transplant
- You have Medicare Part B when getting your prescription filled
If you have Original Medicare, Part B will cover your immunosuppressant medication at 80% of the Medicare-approved amount, meaning that you will be responsible for a 20% coinsurance charge. If you have a Medicare Advantage Plan, contact your plan to learn about its costs and coverage rules for immunosuppressants.
Part D covers your immunosuppressants if you did not have Part A at the time of your transplant or you did not have your transplant in a Medicare-approved facility. Part D coverage for this type of drug typically means higher costs and additional restrictions, such as having to go to specific in-network pharmacies for your drugs.
All Part D formularies must include immunosuppressant drugs. Step therapy is not allowed once you are stabilized on your immunosuppressant drug. Step therapy is a coverage restriction that requires you to try a different or less expensive drug first, before your plan will cover the drug you need. However, prior authorization can apply. This means that your plan may need to verify that Part B will not cover your drugs before providing coverage. Be sure to look for plans that have the fewest coverage restrictions and that have your pharmacies in the preferred network.
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