Does Medicare Cover Prograf?
- Prograf is an immunosuppressant medication used to prevent organ rejection following a transplant. Learn how Medicare Part D coverage for Prograf works.
The last thing you want to worry about when undergoing an organ transplant is how to afford essential medications. Fortunately, your healthcare insurance will likely cover the drugs you need. Below, you can find out how Medicare Part D coverage for Prograf works.
What Is Prograf?
Prograf is a branded version of tacrolimus, an immunosuppressant medication used to prevent your body from rejecting a transplanted organ. Prograf is most commonly prescribed to people receiving a heart, lung or liver transplant.
Prograf comes as an oral suspension or immediate-release capsule. Generic alternatives are available, and other brand names include Astagraf XL, Envarsus XR and FK 506.
Most people take Prograf twice a day following an organ transplant, but it's essential to follow your doctor's instructions precisely. Taking Prograf can increase your chances of developing serious infections, lymphoma and diabetes, so your healthcare provider will monitor you closely during your treatment.
You should contact your provider immediately if you experience severe side effects, such as edema (swelling), unusual bruising or seizures. More common side effects can include:
- Nausea and vomiting
- Changes in skin sensation, such as itching or tingling
- Painful joints
- Stomach pain and indigestion
Does Medicare Cover Prograf?
Although Original Medicare (Parts A and B) doesn't usually cover prescription medications, it may cover doctor-administered medications in limited circumstances. Therefore, regular Medicare may cover your medication if you receive it as a hospital inpatient, although it won't cover drugs taken at home.
However, it's a different story if you have a prescription drug coverage plan (Part D). All Medicare Part D policies cover tacrolimus, although they may not cover the Prograf brand. Your insurer's formulary (list of covered medications) shows which tacrolimus medications your plan covers, and you can usually find them under Tier 2.
Immunosuppressant drugs are one of the six protected drug classes. Therefore, your Medicare Part D provider is legally obligated to cover them. If your plan doesn't cover Prograf, consider asking your doctor for a covered alternative.
How Much Does Prograf Cost With Medicare?
Some Medicare Part D plans may cover Prograf or similar alternatives before you meet your deductible. If yours doesn't, you'll need to pay an amount equivalent to your annual deductible before your insurer starts paying for your medication. Deductibles vary from company to company, but insurers can't set deductibles higher than $480 in 2022.
The cost of Prograf varies widely between pharmacies, and where you live can also affect how much you pay. Prograf is typically more expensive than generic tacrolimus. After meeting your deductible, you'll pay a small co-pay when you receive coverage, and your insurer will cover the rest of your medication costs. Some insurers don't charge co-pays for tacrolimus medications, and you're unlikely to pay more than $2.
Medicare Coverage Restrictions for Prograf
Some Medicare Part D plans impose prior authorization requirements for Prograf and similar medications. A prior authorization requirement means your doctor must contact your insurance company to certify that the drug is medically necessary.