Is Austedo Covered by Medicare? Here’s What You Need to Know

Prescription medications can be life-changing, especially for individuals living with movement disorders such as tardive dyskinesia (TD) or Huntington’s disease. Austedo, a commonly prescribed treatment for these conditions, can significantly improve quality of life—but it often comes with a high price tag. For many seniors and individuals with disabilities, understanding is Austedo covered by Medicare is an integral part of planning for treatment affordability.

This blog explains everything you need to know about how Medicare handles Austedo coverage, including which parts of Medicare may cover it, and how to reduce your out-of-pocket costs if you need this medication.

What Is Austedo and Who Needs It?

Austedo (deutetrabenazine) is a prescription medication approved by the FDA to treat two main conditions:

• Tardive dyskinesia (TD): A disorder that causes repetitive, involuntary movements, often due to long-term use of certain psychiatric medications.
• Chorea associated with Huntington’s disease: A neurological condition that leads to uncontrolled body movements.

The medication aids regulate neurotransmitter activity in the brain to reduce involuntary motions, improving day-to-day comfort and confidence for patients managing these disorders.

Given its specialized use and brand-only availability, Austedo can be pretty expensive without insurance, making it essential to understand the coverage options Medicare provides.

Is Austedo Covered by Medicare?

The answer is yes, Austedo is generally covered by Medicare Part D and most Medicare Advantage (Part C) plans that contain prescription drug coverage. However, the level of coverage and the amount you’ll pay out of pocket can vary depending on your specific plan, tier level, and formulary placement.

Private insurance companies administer Medicare Part D plans, and each plan maintains a list of covered drugs, known as a formulary. Austedo is typically included on this list, but the exact tier and copayment structure can differ. For this reason, it’s crucial to review your plan’s details or speak with your provider to confirm whether Austedo is included and what your share of the cost will be.

How Medicare Part D Covers Austedo?

Medicare Part D is the prescription drug help available to all Medicare beneficiaries. When you enroll in a Part D plan (either standalone or as part of a Medicare Advantage plan), it helps pay for prescription medications approved by the FDA, including specialty drugs like Austedo.

Here’s how the coverage typically works:

1. Formulary inclusion: Austedo is typically classified as a specialty-tier medication, which may result in higher copayments.
2. Prior authorization: Many plans require approval before covering Austedo. Your doctor must confirm that it’s medically necessary and that no cheaper alternatives are effective.
3. Quantity limits: Plans may restrict the amount of medication you can receive per month or require ongoing documentation to continue receiving it.
4. Cost-sharing: Depending on your plan’s deductible and coverage phase, your out-of-pocket costs may vary.

Because of these variables, it’s essential to check the fine print of your Medicare Part D plan before filling your Austedo prescription.

How Medicare Advantage (Part C) Plans Cover Austedo?

If you’re enrolled in a Medicare Advantage plan that includes drug coverage, your Austedo costs will follow the specific rules of your plan. Medicare Advantage plans must cover at least what Original Medicare provides. Still, they often include additional benefits or alternative cost structures.

Here’s what to know:

• Network pharmacies: Always use a preferred pharmacy within your plan’s network to get the lowest price.
• Tier exceptions: You can request a tier exception if Austedo is placed in a high-cost tier, which may result in a lower co-pay.
• Specialty care coordination: Some plans may assist with prior authorizations or connect you with patient assistance programs.

Since Advantage plans are managed regionally, the availability and cost of Austedo may differ depending on your location and insurer.

Out-of-Pocket Costs for Austedo Under Medicare

Even with Medicare coverage, patients may face varying out-of-pocket costs for Austedo depending on their plan stage:

1. Deductible phase: Until your deductible is met, you’ll pay full price for your prescription.
2. Initial coverage phase: After meeting your deductible, you spend a co-pay or coinsurance based on your plan’s drug tier.
3. Coverage gap (donut hole): Once your total drug costs reach a certain threshold, you’ll pay a percentage of the medication cost (usually around 25%).
4. Catastrophic coverage: Once your spending exceeds the out-of-pocket threshold, your costs significantly drop for the remainder of the year.

Because Austedo is a specialty drug, patients may reach these thresholds more quickly. Understanding these phases helps you anticipate your expenses throughout the year.

Steps to Confirm Austedo Coverage

To make sure your Medicare plan covers Austedo:

1. Check your plan’s formulary: Look for Austedo or its generic counterpart (if available) on the official list.
2. Ask your pharmacy: Pharmacists can verify your plan’s coverage and estimate your co-pay or coinsurance.
3. Call your insurance provider: Confirm any prior authorization requirements and cost-sharing details.
4. Consult your healthcare provider: They can assist with authorization requests or documentation if needed.

If Austedo is not on your plan’s formulary, your doctor can request a formulary exception—a formal request for your plan to cover a medication it doesn’t usually include.

Assistance Programs That May Help

For patients who find Austedo’s cost unaffordable even with Medicare coverage, several assistance options exist:

• Manufacturer programs: The maker of Austedo often offers savings cards or patient assistance programs for eligible individuals.
• State pharmaceutical assistance programs (SPAPs): Some states help Medicare beneficiaries with prescription costs.
• Extra Help (Low-Income Subsidy): A federal program that helps low-income individuals reduce or eliminate prescription drug costs under Medicare Part D.
• Nonprofit foundations: Organizations like the PAN Foundation and Patient Advocate Foundation may offer grants or co-pay assistance.

Exploring these options can help make treatment with Austedo more accessible and sustainable.

Alternatives and Generic Options

As of now, Austedo does not have a generic equivalent in most markets. However, other medicines, such as tetrabenazine, may be prescribed for similar conditions. It’s important to note that each drug has its own side effects, dosing schedules, and cost considerations.

Before switching medications, always consult your neurologist or prescribing physician. They can help resolve whether an alternative offers comparable benefits and verify whether it’s more affordable under your Medicare plan.

Tips to Manage Costs and Stay Covered

If you’re driving a chronic condition that requires Austedo, consider these tips to minimize expenses:

• Use preferred pharmacies: They often offer lower co-pays within your Medicare plan’s network.
• Enroll in Extra Help: If eligible, this can drastically reduce prescription costs.
• Track your spending: Understanding where you stand in your coverage phases prevents surprises.
• Reevaluate your plan annually: During the Medicare Annual Enrollment Period (October 15 to December 7), compare plans to assure you’re getting the best value.
• Ask your doctor for samples: Some physicians may provide samples while you wait for coverage approval or enrollment in an assistance program.

Proactive management can prevent coverage interruptions and keep treatment affordable.

Conclusion

If you’ve been wondering if does Medicare cover Austedo, the answer is yes—most Medicare Part D and Medicare Advantage plans do supply coverage, though your out-of-pocket costs will vary. The key to managing your prescription expenses lies in understanding your plan’s formulary, navigating the coverage stages, and taking advantage of available financial assistance programs.

By staying educated, coordinating with your doctor, and reviewing your plan annually, you can ensure continuous access to the medication you need while keeping your healthcare costs under control.

Disclaimer: This article is for informational purposes only and is not intended as medical or financial advice. Medicare coverage details vary by plan and region. Always consult your plan provider and healthcare professional for personalized guidance.