Medicare Prescription Plans cover Paxlovid but you could have a high out of pocket cost for the medication

Medicare will help pay for treatment options such as doctor visits or a hospital stay, but you may have a high cost for medications such as Paxlovid.

Medicare Part D Rx and Medicare Advantage Plans

You can get your prescription coverage either through a Medicare Part D standalone policy or included with a Medicare Advantage plan.  Medicare Part D plans can have a deductible, some plans have a $0 deductible and others have up to $590 annual deductible.  This deductible can either apply to all prescriptions or just to higher tier (typically brand name) medications.

Plaxlovid and other similar medications to help with the symptoms of COVID 19 are considered higher tier medications, either Tier 3 or Tier 4.  The cost of these medications very expensive, they could be over $1,000 for one bottle. 

If someone has not hit their deductible yet they could have to spend down the entire deductible (up to $590) Paxlovid and then owe the cost share for the Tier 3 medication after the deductible.  The cost share with many plans is 25%. 

If the deductible for a prescription plan has not been met, then one prescription of Paxlovid could cost $700+ out of pocket.  If the prescription is $1,000 then the deductible would be charged first, $590, then the insurance pays 75% and you owe 25%, $102.50.  So you’d owe $692.50 if the prescription is $1,000 for one bottle.

If you’re enrolled in a Medicare Part D or Medicare Advantage plan without a deductible then you’d only owe the cost for a Tier 3 medication.  For some plans this is a straight copayment, eg $40, while others charge a percentage of the prescription, eg 25%.

All Medicare prescription plans have a $2,000 maximum out of pocket per year in 2025.

U.S. Government Patient Assistance Program (USG PAP)

Individuals whose income is below $46,950 individually or $63,450 as a couple, may qualify for Patient Assistance Programs to help get Paxlovid at no charge.

Pfizer the manufacturer of Paxlovid, operates a patient assistance program that provide eligible Medicare beneficiaries with free Paxlovid access until December 31,2025. This program is also available to individuals with Medicaid, TRICARE < VA Community Care Network, and those without insurance.

How to access the USG PAP:

If you have a valid Paxlovid prescription, you can enroll in this assistance program online on their website, Paxlovid.iassist.com or over the phone by calling 877-219-7225.

The enrollment process is typically quick and can be completed by you, a caregiver, or your healthcare provider. Once approved, you’ll receive a voucher or copay card to present at participating pharmacies. Always confirm with your pharmacy that they participate in the assistance program.

 

Medicare Coverage for Covid 19

If you develop COVID-19 symptoms, Medicare provides coverage for various COVID-19 related services and treatment including:

COVID-19 Vaccines and Boosters:
Medicare covers FDA-approved COVID-19 vaccines and booster shots at no cost to you

Diagnostic Tests:
Medicare Part B covers FDA-authorized COVID-19 diagnostic laboratory tests when ordered by a healthcare provider. This includes test done at pharmacies, clinics, doctor’s offices, or hospitals that accept Medicare.

Monoclonal Antibody Treatments:

Provided you meet certain conditions, under Medicare Plan B you generally pay nothing for these treatments when received from a Medicare FDA-approved provider or supplier.

 Medically Necessary Hospitalizations:

Should you require hospitalization for COVID-19, Medicare will cover medically necessary inpatient stays. Standard deductibles, copays, or coinsurance may apply.

We understand that navigating healthcare coverage can be complex, our goal is to empower you with the information you need to make informed decisions about your health. If you have any questions or need further assistance please don’t hesitate to reach out to us!