Does Medicare Cover Januvia? 

Diabetes is a big healthcare concern in America and according to the Endocrine Society, close to one-third of American seniors are believed to be living with diabetes. Diabetic seniors face the same challenges as younger diabetics, but because it’s often harder to lose weight with age, simple lifestyle changes may not be enough to fight diabetes. In these cases, doctors may prescribe medications like Januvia to help combat the effects of type II diabetes.

What is Januvia?

Januvia (sitagliptin) is a prescription drug designed to treat type II diabetes; however, it is not to be used in seniors with type I diabetes. Januvia works by balancing the production of insulin against the amount of blood glucose processed in the liver.

With use as prescribed by your doctor, you may be able to reduce diabetes symptoms and risk by taking Januvia. There is a risk of developing health concerns with your pancreas while taking Januvia, so you will want to discuss your health with your doctor prior to beginning your prescription.

Does Medicare cover Januvia?

Seniors and retirees in the United States can use Medicare benefits to pay for prescription drugs through Medicare Part D. This prescription drug benefit helps to pay for medications that can be purchased from retail pharmacies, but it does not cover medications that need to be injected or infused.

Each Medicare Part D plan includes a list of covered medications called a formulary. Medicare recipients will need to consult this list to determine if Januvia is covered. A Part D formulary usually lists different coverages for brand-name and generic medications, but Januvia has no generic version available.

Prescription drug coverage and Januvia

If your Medicare coverage includes Januvia under your Part D benefits, your formulary should tell you what you can expect to pay. Many drugs under Part D require a copay that is charged when you pick up your medication.

Drugmakers also sometimes offer discount programs for different groups of people, including those on Medicare. To learn whether you qualify for any discount plan regarding the medications you take, you will need to contact the maker of each medication you are prescribed.

Your costs for Medicare Part D

Medicare Part D is optional coverage that requires a monthly premium. Medicare recipients pay differing premiums based on their taxable income. For most, the only cost involved is the plan premium.

For Medicare recipients with higher incomes, an additional premium is charged that increases as your reported income rises. The highest additional premium charged by Medicare insurance is $76.40 per month for individuals making $500,000 or more per year or married couples making $750,000 per year.

Medicare Part D also requires that you meet a deductible before you can begin using your Medicare benefits for prescription drugs. In 2024, the deductible for Part D coverage can be no more than $545 per benefit period.

Outpatient coverage of Januvia

Medicare benefits cover outpatient treatment through Medicare Part B. This is the part of Medicare that is used for doctor visits and clinical treatment, so it generally does not apply toward the cost of Januvia. You may, however, need to use Part B coverage in the event that you are hospitalized and a doctor from outside of the hospital’s staff administers Januvia.

Inpatient coverage of Januvia

While admitted to a Medicare-participating hospital or skilled nursing facility, inpatient treatment is covered for a limited number of days per benefit period. If Januvia is prescribed and administered during inpatient treatment, Medicare Part A covers the cost.

Medicare Part A covers 60 days of hospital care or 20 days of skilled nursing facility (SNF) care per benefit period. Medicare recipients can utilize an additional 30 days of hospital care or 80 days of SNF care at a discounted per-day fee each benefit period. Once these days have been used, Medicare benefits can only be extended by using lifetime reserve days.