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How Much Does Rexulti Cost with Medicare?

The cost of Rexulti with Medicare varies considerably depending on your specific Medicare plan, your formulary stage, and whether you qualify for Extra Help (Low-Income Subsidy). Generally, you can expect to pay anywhere from $2 to over $500 per month for Rexulti. This wide range is due to the complex structure of Medicare prescription drug coverage (Part D) and the different cost-sharing models employed by different plans. The best way to get an accurate estimate for your individual situation is to check your specific Medicare Part D plan’s formulary and contact your plan provider directly.

Understanding Rexulti and Its Use

Rexulti (brexpiprazole) is an atypical antipsychotic medication primarily used to treat:

Schizophrenia: Rexulti can help manage symptoms like hallucinations, delusions, and disorganized thinking.
Major Depressive Disorder (MDD): It is often used as an adjunctive treatment, meaning it’s prescribed alongside an antidepressant to enhance its effectiveness.

Rexulti works by affecting the activity of certain neurotransmitters in the brain, specifically dopamine and serotonin. Because of its efficacy in treating these mental health conditions, understanding its cost under Medicare is crucial for many beneficiaries.

Factors Influencing Rexulti Cost Under Medicare

Several factors influence the final cost of Rexulti when you have Medicare:

Medicare Part D Plan: Different plans have different formularies (lists of covered drugs) and cost-sharing structures. Some plans may not cover Rexulti at all, while others may place it on a higher tier, resulting in higher copays or coinsurance.
Formulary Tier: The tier a drug is placed on within a formulary directly affects its cost. Higher tiers typically have higher costs. Rexulti is often placed on a higher tier due to it being a brand-name medication.
Deductible: Many Medicare Part D plans have an annual deductible that you must meet before your prescription drug coverage kicks in. If you haven’t met your deductible, you’ll pay the full retail price of Rexulti until you do.
Initial Coverage Phase: After you meet your deductible, you enter the initial coverage phase, where you typically pay a copay or coinsurance amount for your prescriptions.
Coverage Gap (Donut Hole): Once you and your plan have spent a certain amount on covered drugs (the coverage gap threshold), you enter the coverage gap. While in the coverage gap, you’ll pay no more than 25% of the plan’s negotiated price for covered brand-name drugs, and a portion of the drug manufacturer’s discount counts toward your out-of-pocket costs.
Catastrophic Coverage: After you reach a certain out-of-pocket spending limit (the catastrophic coverage threshold), you enter catastrophic coverage. During this phase, you typically pay a very small copay or coinsurance amount for covered drugs.
Extra Help (Low-Income Subsidy): If you have limited income and resources, you may qualify for Extra Help, which helps pay for Medicare prescription drug costs. If you qualify, you’ll likely pay significantly less for Rexulti.

How to Find Your Rexulti Costs

Review Your Medicare Part D Plan Formulary: This document lists all the drugs covered by your plan and their tier placement. You can usually find the formulary on your plan’s website or request a copy from your plan provider. Look for “brexpiprazole” on the list.
Contact Your Medicare Part D Plan Provider: Call your plan’s customer service line. Ask them about the cost of Rexulti at your current formulary stage. Provide them with your member ID and any other relevant information.
Use Medicare’s Plan Finder Tool: This tool allows you to compare different Medicare plans in your area and see their estimated costs for specific drugs. While it’s a helpful tool, it’s always best to confirm the information with the plan directly.
Check with Your Pharmacy: Ask your pharmacist to run your prescription through your insurance to see the estimated cost. This will give you a real-time estimate based on your coverage.

Strategies for Reducing Rexulti Costs

Even with Medicare, Rexulti can be expensive. Here are some strategies to potentially lower your costs:

Compare Medicare Plans Annually: Medicare plans can change their formularies and costs each year, so it’s crucial to compare plans during the annual enrollment period to ensure you have the best coverage for your needs and medications.
Apply for Extra Help: If you have limited income and resources, apply for Extra Help (Low-Income Subsidy) through the Social Security Administration. This can significantly lower your prescription drug costs.
Talk to Your Doctor: Discuss alternative medications with your doctor. While Rexulti may be the most appropriate treatment for you, there might be less expensive options available.
Manufacturer’s Patient Assistance Programs: Check if the manufacturer of Rexulti, Otsuka Pharmaceutical, offers any patient assistance programs that can help with the cost of the medication.
Consider a Different Pharmacy: Prices can vary between pharmacies, even within the same plan network. Shop around to see if you can find a pharmacy with lower prices.
GoodRx: While GoodRx is typically used for uninsured individuals, it can sometimes offer lower prices than your copay, so always check GoodRx before filling your prescription.

Rexulti and Medicare FAQs

1. Is Rexulti covered by Medicare Part D?

Generally, yes, Rexulti is covered by most Medicare Part D plans. However, coverage can vary between plans. You need to check your specific plan’s formulary to confirm coverage and tier placement.

2. What if my Medicare Part D plan doesn’t cover Rexulti?

If your plan doesn’t cover Rexulti, you have a few options:

Request a Formulary Exception: Ask your doctor to submit a formulary exception request to your plan, explaining why Rexulti is medically necessary for you.
Switch Plans: During the annual enrollment period, you can switch to a plan that covers Rexulti.
Pay Out-of-Pocket: If neither of the above options work, you may have to pay the full retail price for Rexulti.

3. How does the Medicare Coverage Gap (Donut Hole) affect Rexulti costs?

During the Coverage Gap, you’ll pay no more than 25% of the plan’s negotiated price for Rexulti. While this is an improvement over paying the full price, it can still be a significant cost.

4. How can I find out if I qualify for Extra Help (Low-Income Subsidy)?

You can apply for Extra Help through the Social Security Administration (SSA). You can apply online, by phone, or in person. The SSA will assess your income and resources to determine your eligibility.

5. What is a formulary exception, and how do I request one?

A formulary exception is a request for your Medicare plan to cover a drug that is not on its formulary or to waive coverage restrictions. Your doctor must submit the request, providing medical justification for why Rexulti is necessary and why other covered drugs would not be as effective.

6. Can I appeal if my Medicare plan denies coverage for Rexulti?

Yes, you have the right to appeal if your Medicare plan denies coverage for Rexulti. Your plan will provide instructions on how to file an appeal.

7. Is there a generic version of Rexulti available?

As of the current date, there is no generic version of Rexulti available in the United States. This means that you’ll likely pay more for Rexulti than you would for a generic medication.

8. How often can Medicare Part D plans change their formularies?

Medicare Part D plans can change their formularies at any time, but they must provide beneficiaries with at least 60 days’ notice before removing a drug from the formulary or changing its tier placement.

9. What is the difference between a copay and coinsurance?

A copay is a fixed amount you pay for a prescription, while coinsurance is a percentage of the drug’s cost that you pay. Your Medicare plan will specify whether you pay a copay or coinsurance for Rexulti.

10. Where can I find the Medicare Plan Finder tool?

You can find the Medicare Plan Finder tool on the official Medicare website (medicare.gov). This tool allows you to compare different Medicare plans and their costs.

11. Can I use a manufacturer coupon with Medicare Part D?

Generally, you cannot use manufacturer coupons to lower your cost-sharing under Medicare Part D. These coupons are typically intended for individuals without insurance or who have commercial insurance.

12. What resources are available to help me understand Medicare Part D?

Several resources can help you understand Medicare Part D:

Medicare.gov: The official Medicare website provides comprehensive information about Medicare benefits.
State Health Insurance Assistance Programs (SHIPs): These programs offer free, unbiased counseling to Medicare beneficiaries.
Your Medicare Plan Provider: Your plan provider can answer questions about your specific coverage.
Social Security Administration (SSA): The SSA can provide information about Extra Help (Low-Income Subsidy).