Does Medicare Cover Accutane?

Acne is a prevalent problem among many adolescents and young adults. And Medicare is primarily a health insurance program for senior citizens. However, what many people don’t know is that some seniors can still have issues with acne.

There are a number of treatments available for acne. One of the common ones is a drug called Accutane.

If you are a senior who is dealing with acne, one question you likely have is “Does Medicare cover Accutane?” In this article, we answer the question in clear, plain English. You will also find the average costs of Accutane and other helpful info about this drug.

The short answer is no. In most cases, Medicare will not cover the cost of Accutane. That said, there may be certain situations where you can get these costs covered. Below we’ll take a closer look at this to see when you might be able to get Medicare to pay for your Accutane.

Original Medicare Coverage of Accutane

Original Medicare (Medicare Part A and Part B) does not provide coverage for Accutane. That is because Original Medicare mainly covers medically necessary services, equipment, and treatments.

This typically does not include prescription drugs. Prescription drug coverage may be provided by either Medicare Advantage plans or Medicare Part D.

Medicare Advantage Coverage of Accutane

On the other hand, some Medicare Advantage plans (Medicare Part C) provide coverage for Accutane.

The Advantage plans cover everything Original Medicare covers and some additional benefits. This can include prescription drug coverage. The specifics of what is covered will depend on the Part C plan that you have.

Medicare Part D’s Plan Coverage

Medicare Part D plans may also provide coverage for Accutane (or, at least a generic version of the drug). Part D is a prescription drug plan. Like Medicare Part C, Medicare Part D plans are provided by private insurance companies.

Eighty-seven percent of both Medicare Part C and Part D plans provide coverage for the medication Accutane.

Limitations on Accutane under Medicare

Most Medicare plans restrict the amount of purchase for Accutane per one time. If you need to purchase a greater amount of Accutane at one time, Medicare may not cover it.

If this happens to you, you can either wait until the period has passed before refilling your prescription. Or, if you need to purchase greater amounts of Accutane in just one purchase, you can contact your plan provider and ask for an exception.

More on Accutane Prescriptions Under Medicare

Accutane is listed as a tier 4 drug in the Medicare drug formulary. Often the Medicare drug formulary only has five tiers. Tier 4 medications are branded, more expensive medications. Tier 4 medications are more expensive than Tier 1, 2, and 3.

Both Part C and Part D plans also provide coverage for Isotretinoin, the generic version of Accutane.

Eighty-six percent of both Medicare Part C and Part D plans provide coverage for the medication Isotretinoin.

How Much Does Accutane Cost?

The average cost of 30 capsules of 40mg Accutane is $542.43 if you have to pay for it out of pocket.

Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage. Always be sure to double check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.