Does Medicare Cover Mycophenolate?

If your doctor tells you to take mycophenolate, you may be wondering whether your Medicare plan covers your medication. Mycophenolate is an expensive drug, so knowing what you'll pay can provide much-needed peace of mind. Below, you can find out whether Medicare covers mycophenolate and how much you'll pay out of pocket. 

What Is Mycophenolate Used For?

Mycophenolate is an immunosuppressant drug that suppresses your immune system to stop your body from attacking a transplanted organ. It may also be used to treat Crohn's disease.

Doctors typically prescribe Cellcept (mycophenolate) to adults who receive heart and liver transplants and children who receive a transplanted kidney. Meanwhile, Myfortic (mycophenolic acid) is commonly used to prevent organ rejection in adults after a kidney transplant. Typically, mycophenolate forms part of a treatment regimen with other antirejection medications. 

Mycophenolate is available as capsules, tablets and liquid suspensions. You'll usually need to take mycophenolate twice a day on an empty stomach. However, your doctor may recommend a different schedule, and you should take your medication exactly as directed. Cellcept and Myfortic work differently from each other, so it's essential to check that the pharmacy gives you the type prescribed by your healthcare provider. 

Mycophenolate Side Effects

Mycophenolate can cause various side effects. These include:

• Gastric pain and swelling
• Constipation
• Changes in skin sensation, such as pins and needles or burning
• Headache
• Insomnia
• Nausea and vomiting
• Joint and muscle pain or stiffness

You should seek urgent medical care if you experience severe side effects, such as breathing difficulties or chest pain. Mycophenolate can also cause birth defects. Therefore, you should use reliable birth control throughout your treatment and for at least 90 days after completion if there is a chance you or your partner could become pregnant.

Does Medicare Cover Mycophenolate?

All Medicare prescription drug plans (Medicare Part D) cover Cellcept. Meanwhile, around 84% of Medicare Part D policies cover Myfortic. You can determine whether your policy includes Myfortic by checking its formulary, which lists the medications covered by your plan. Most insurers list Myfortic under Tier 4. 

How Much Does Mycophenolate Cost With Medicare?

How much you'll pay for your mycophenolate prescription depends on whether you've met your Medicare Part D deductible. Typically, your plan will begin paying for your medication once you've paid your annual deductible, although some providers will cover specific treatments before this point. The 2024 deductible limit is $545, although some insurers offer zero or significantly lower deductibles. 

The period before you meet your deductible is the deductible stage. Generally, you'll pay the total cost of your medication during this stage. Cellcept costs $354.45 on average for 60 500-milligram tablets. Meanwhile, 60 360-milligram Myfortic capsules cost around $512.44 on average. 

The Post-Deductible stage begins once you meet your deductible. You'll then pay a modest co-pay for your medication while your insurer covers the remainder. Expect to pay between $0 and $2 for Cellcept and between $0 and $6 for Myfortic.

Does Medicare Restrict Coverage for Mycophenolate?

Most Medicare Part D plans require prior authorization before agreeing to cover mycophenolate. Prior authorization means the prescribing doctor must contact your provider to verify that the medication is medically necessary.