Does Medicare Cover Focalin?

In this article...
  • Find out whether Medicare covers Focalin and Focalin XR, including information about out-of-pocket costs, coverage restrictions and common Focalin side effects.

If you have ADHD, your doctor may prescribe medication alongside other therapies. Medications used to treat ADHD can be expensive, but your Medicare policy may cover some of the costs. Let's explore whether Medicare covers Focalin and other similar medications. 

What Is Focalin?

Focalin is a stimulant commonly prescribed to people with attention deficit hyperactivity disorder (ADHD.) It's a branded version of the generic drug dexmethylphenidate, which stimulates the central nervous system to improve focus and reduce restlessness. 

Focalin comes in two forms: immediate-release tablets and extended-release capsules. The extended-release version is called Focalin XR. Extended-release tablets can interfere with sleep, so your doctor may recommend taking your medication in the morning to mitigate the effects. 

It's essential to take Focalin precisely as prescribed by your doctor because taking too much can be habit-forming. You should always consult your healthcare provider before increasing your dose, even if you feel your current dose doesn't provide adequate symptom relief. Seek medical advice if you notice signs of dependency, such as a strong desire to take your medication or needing to take more to achieve the same effects. 

Occasionally, Focalin can cause heart or blood vessel problems. Your doctor will monitor you closely while you take the medication, and you should seek advice if you experience cardiovascular symptoms, such as chest pain or fainting. Other side effects may include:

  • Anxiety
  • Reduced appetite and weight loss
  • Tiredness
  • Low mood or mood swings
  • Agitation
  • Feelings of sadness or emptiness
  • Loss of interest in things you usually enjoy

Does Medicare Cover Focalin?

Original Medicare (Parts A and B) doesn't typically cover prescription medications. However, you can purchase a supplementary Medicare Part D (prescription drug coverage) policy for a monthly premium through approved private insurers. 

Around 88% of Part D plans cover Focalin, but they don't usually cover Focalin XR. The only way to determine whether your policy covers these medications is to check your insurer's coverage list, known as the formulary. Most companies class Focalin as a Tier 2 drug, although this can vary by provider. If your policy doesn't cover the Focalin brand, it may cover generic dexmethylphenidate or dexmethylphenidate XR.

How Much Does Focalin Cost With Medicare?

Most Medicare Part D plans don't pay for your prescription medication right away, although they may allow immediate coverage for certain drugs. Instead, you'll need to meet your annual deductible before claiming for prescription medications, such as Focalin. The legal cap for Part D deductibles is $480 as of 2022. Some policies don't charge deductibles, but they usually require steep monthly premiums. 

You must meet the full costs of your Focalin prescription until you've covered the deductible. How much you'll pay depends on various factors, including where you live. On average, Focalin costs $91.63 for 60 10-milligram tablets. Focalin XR is significantly more expensive, costing an average of $252.94 for 30 10-milligram capsules. 

Once you've met your deductible, you'll usually pay a co-pay every time you receive coverage. Your insurer then covers the balance of the cost of your medication. Some companies don't charge co-pays for Focalin, and most charge no more than $11.

Does Medicare Restrict Focalin Coverage?

Most Medicare plans that cover Focalin impose quantity limits because of the medication's habit-forming potential. This means you can only receive a limited amount of your medication each time you fill a prescription.

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