Is Repatha (evolocumab) covered by Medicare Part B?
Repatha coverage depends on how it’s administered and billed.
Medicare Part B generally covers items and services that are furnished “incident to” a physician’s service (commonly injections given in a clinical setting). Repatha is typically a self-injectable medication used at home, which is usually billed under Part D rather than Part B.
When would a Repatha prescription fall under Part B instead?
Part B coverage is most likely only if the drug is administered by a provider in a covered clinical setting in a way that fits Part B billing rules (for example, if it’s given in an outpatient facility/clinic and billed accordingly). If you’re using the prefilled autoinjector or syringe at home, that use is usually treated as Part D.
What if it’s not covered under Part B?
If Repatha is billed as a home/self-administered drug, it is usually covered through a Medicare Part D prescription drug plan. Coverage then depends on your plan’s formulary and your specific circumstance (diagnosis, documentation requirements, and prior authorization).
How to check coverage for your specific situation
The quickest way to confirm is to check:
1) your Part D plan formulary (if you take it at home), or
2) ask your prescriber/pharmacy whether it would be billed under Part B for your administration setting.
If you tell me whether you inject at home or receive it in a clinic (and which Medicare plan type you have: Part B only, or Part B plus Part D), I can help you pinpoint the most likely billing path.