Does Medicare Cover Imbruvica?

Imbruvica is a medication that is used to treat certain types of cancers. This medication targets the proteins in cancer cells and stops the cancer cells from growing. It can treat certain cancers such as many types of lymphoma as well as leukemia.

If this is a treatment that can help you or a loved one, a common question people ask is “does Medicare cover Imbruvica?” In this article, we answer that question in clear, plain English. You will also find information about the average costs of Imbruvica.

The short answer is no. In most cases, Medicare will not cover the cost of Imbruvica. That said, there may be some 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 Imbruvica.

Original Medicare

Original Medicare (Medicare Part A and Part B) does not provide coverage for Imbruvica. That is because Original Medicare mainly covers medically necessary services, equipment, and treatment rather than prescription drugs. At this point, Imbruvica is not considered medcially necessary. However, prescription drug coverage may be provided by either Medicare Advantage plans or by Medicare Part D.

Part C and Part D Coverage for Imbruvica

However, some Medicare Advantage plans (Medicare Part C) provide coverage for Imbruvica. Medicare Advantage plans will cover everything Original Medicare covers. However, they offer additional benefits too. Exactly what each plan covers and what the out-of-pocket costs are for the coverage depends on the plan you have.

Medicare Part C plans that include prescription drug plans will also provide coverage for medications that your healthcare provider will prescribe to you.

Medicare Part D plans also provide coverage for Imbruvica. Part D is a prescription drug plan, and just like Medicare Part C, Medicare Part D plans are provided by private insurance companies. 100 percent of both Medicare Part C and Part D plans provide coverage for the medication Imbruvica.

Most Medicare plans restrict the amount of purchase for Imbruvica per one time. If you need to purchase a greater amount of Imbruvica at one time, Medicare may not cover it. You can either wait until the period has passed before refilling or contact your plan provider and ask for an exception.

Imbruvica is listed as a Tier 5 drug in the Medicare drug formulary. Most of the time, the Medicare drug formulary only has 5 tiers. Tier 5 medications are more expensive than Tier 1, 2, 3, and 4 medications.

Most Medicare plans also may require you to have prior authorization before they provide coverage for this medication. The usage of this medication has to be for medically necessary purposes. You must contact your plan provider to get authorization.

How Much Does Imbruvica Cost?

The cost of Imbruvica is $490 per capsule/tablet. Regardless of the medication’s dosage, the price remains the same. Imbruvica comes in 70mg, 140mg, 280mg, 420mg, and 560mg. The exact dosage that you should take will depend on the type of condition that you need to treat.

Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage and Medigap plans. 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.