Does Medicare Cover Trulicity?
Original Medicare does not cover medication; however, most Medicare Advantage and Part D prescription drug plans will cover Trulicity if a doctor prescribes it as medically necessary.
Part of a new class of medications called incretin mimetics, Trulicity imitates incretin hormones and binds to GLP-1 receptors to stimulate glucose-dependent insulin release. These weekly, self-administered injections allow Type 2 diabetes patients to conveniently regulate their blood sugar levels in combination with diet and exercise.
Private companies sponsor Medicare prescription coverage, meaning out-of-pocket Trulicity costs depend on your policy details and insurer. Due to the high market price of the drug, Trulicity typically comes with a higher copayment than plan-preferred or generic pharmaceuticals.
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What Is Trulicity?
Trulicity comes in prefilled syringes of varying dosages that patients can administer themselves. These injections replace or supplement naturally occurring glucagon-like peptide-1 (GLP-1) in the body, regulating appetite and blood sugar through the following responses:
- Slowing digestion to prevent blood sugar from spiking after meals
- Helping the body produce more insulin to manage rising blood sugar levels
- Preventing the liver from releasing excessive glycogen into the bloodstream
The effects of Trulicity last for about a week, at which point patients need to re-administer the medication. Recent studies have shown Trulicity to reduce blood sugar levels by close to or greater than 1% and for its effects to last longer than other diabetes medications.
Understanding Medicare Coverage for Trulicity
Getting Trulicity covered through Medicare depends on your medical eligibility and the details of your prescription drug plan.
To secure Trulicity through Medicare, you must meet the following requirements:
- You have a supplementary prescription drug plan (PDP).
- A Medicare-approved physician must prescribe Trulicity as medically necessary in managing your Type 2 diabetes.
- You must meet Medicare eligibility, meaning you’re older than 65 and or have a specific disability that allows you to access Medicare and its affiliated PDPs.
People with Type 1 or gestational diabetes will not require Trulicity, nor will Medicare extend them coverage.
You can only access Part D benefits by purchasing a standalone policy after enrolling in Original Medicare or securing coverage as part of a Medicare Advantage Plan (MA-PD). Your insurer will only pay for Trulicity and other pharmaceuticals included on its official list of covered drugs, known as a formulary.
Part A Coverage
Original Medicare Part A (Hospital Insurance) pays for inpatient care received in a hospital, skilled nursing facility, or nursing home, as well as supplies and equipment like beds and bandages. Though Part A will pay for certain pharmaceuticals administered by hospital staff, it does not cover prescription drugs. Therefore, Part A does not cover Trulicity.
Part B Coverage
Original Medicare Part B (Medical Insurance) covers preventative care, medically necessary doctor’s services, and certain supplies prescribed to diagnose, treat, or prevent health concerns. While it never directly pays for Trulicity, Part B will cover 80% of a preventative care visit to the Medicare-approved doctor who ultimately writes your prescription.
Part D Coverage
Original Medicare beneficiaries who want prescription drug benefits must purchase a standalone Part D policy. Since private companies govern each PDP independently, they all impose varying out-of-pocket costs, coverage restrictions, and drug formularies. Once a doctor prescribes Trulicity as medically necessary, Original Medicare members can use the online plan finder tool to purchase a compliant Part D policy and compare prices at local pharmacies.
While 99% of Part D drug formularies include Trulicity, they typically cover it as a tier 3 (or “specialty”) medication. Drugs in this category almost always require policyholders to pay a higher copayment to fill each prescription.
How Does Medicare Advantage Cover Trulicity?
Medicare Advantage must legally cover all the same services as Original Medicare and often rolls additional benefits like dental care and prescription drugs into one bundled policy. In 2023, 89% of Medicare Advantage plans include prescription drug coverage. Although details vary by plan, 99% of MA-PD policies will pay for Trulicity.
How Much Does Trulicity Cost With Medicare?
Most Medicare prescription drug plans rank Trulicity as a tier 3 medication, meaning patients pay more out of pocket than they would for other pharmaceuticals. While the Inflation Reduction Act has capped senior insulin spending and prompted cost regulations for highly-sold drugs that lack a generic alternative, Trulicity is not yet eligible for negotiations due to its relative recency on the market.
Original Medicare Costs
Because patients inject Trulicity themselves, Original Medicare Part A and Part B will not cover it as a hospital-administered medication or an outpatient doctor’s procedure. Therefore, Original Medicare members without supplemental pharmaceutical coverage must pay 100% of a Trulicity prescription out-of-pocket. The current list price for the drug sits at $931 a month.
Medicare Part D Costs
Out-of-pocket costs for Trulicity purchased under Medicare Part D can vary depending on numerous factors. For one, the private companies that sponsor these policies all impose independent premiums, deductibles, and coinsurance rates. Your Trulicity coinsurance or copayment also depends on where the drug ranks in your plan’s formulary. Prices increase through the following tiers:
- Preferred or generic drugs (low-cost)
- Non-preferred or name-brand drugs (higher-cost)
- Specialty drugs (highest-cost)
- Uncovered drugs
The CMS defines specialty drugs as those that cost more than $830 per month, which often applies to moderate or high-dose Trulicity prescriptions. 76% of Part D plans charge the minimum 25% coinsurance for tier 3 drugs. Regardless of a medication’s ranking, its Part D deductible cannot exceed $505.
Medicare Advantage Costs
As with PDPs, MA-PD costs for Trulicity vary depending on your chosen insurer, pharmacy, and policy details. 76% of MA-PD plans charge the maximum 33% coinsurance for tier 3 drugs, including Trulicity. However, most of these policies also waive some or all of the standard deductible for high-cost, specialty pharmaceuticals.
Putting It All Together
If you have Type 2 diabetes, your doctor may prescribe Trulicity. While not a viable replacement for insulin, diet, and exercise, this relatively new drug can effectively regulate blood sugar levels for longer-lasting periods than many other diabetes medications.
Most Medicare Part D and Medicare Advantage prescription drug plans pay for Trulicity. However, due to the drug’s high market price and lack of generic alternatives, coverage usually comes with higher coinsurance and copayment rates. If you need help paying for Trulicity, explore financial aid programs like Medicare Extra Help or compare PDP and MA-PD plans with more favorable benefits.