Does Medicare Cover Januvia?

The Centers for Disease Control and Prevention (CDC) reports that “more than 34 million Americans have diabetes (1 in 10), and approximately 90-95% of them have Type 2 diabetes.” Januvia is a prescription drug that treats Type 2 diabetes.

Medicare Benefits Solutions

Nov 15, 2021

 3 minutes read

Type 2 diabetes

When you eat, carbohydrates break down into their simplest form of sugar, called glucose or blood sugar. Glucose has an important job to do. It enters the bloodstream and permeates your cells to produce energy. But it can’t perform this vital function without the proper amount of a hormone called insulin. 

According to the American Diabetes Association, “Type 1 diabetes is when your body does not produce insulin. Type 2 diabetes is the most common form of diabetes – and it means that your body doesn’t use insulin properly.”

Type 2 diabetes is associated with: 

  • Insulin deficiency: The pancreas does not make enough insulin for the glucose to move into the cells.
  • Insulin resistance: Normally, the liver stores the extra glucose in the form of glycogen, converting it back to glucose and releasing it into the bloodstream when your insulin is low. If the liver does not detect insulin, it may release more glucose than it should.

Benefits and risks of Januvia

The Federal Drug Administration (FDA) approved Januvia for Type 2, but not Type 1, diabetes. It is a brand-name drug not available in generic form. If you have Type 2 diabetes, your doctor may prescribe Januvia to help you: 

  • Maintain stable insulin levels
  • Lower your body’s production of blood sugar

As with all drugs, discuss potential side effects with your doctor. For Januvia, Medical News Today lists these side effects as the most common:

  • Upper respiratory infections, including a cold or sinus infection
  • Nasal congestion or runny nose
  • Headache

More severe side effects include:

  • Hypoglycemia
  • Allergic reactions
  • Kidney issues
  • Joint discomfort
  • Pancreatitis

If you experience any side effects, make your doctor aware.

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Medicare Part D

of these plans:  

  • Medicare drug plan that adds prescription drug benefits to Original Medicare
  • Medicare Advantage Drug Plan (MAPD), which is a Medicare Advantage plan that bundles Part A, B and D under one policy

Your drug plan should provide you with a list of approved drugs, called a formulary. Search the formulary to see if Januvia is listed, and pay close attention to coding that indicates any limitations, such as:

  • QL: quantity limits
  • PA: prior authorization
  • MO: mail-order delivery
  • GC: gap coverage

Costs are typically associated with the tier on which the drug appears. Tiers can vary with the plan, but generally, the lowest tiers are generic drugs and are the least expensive. The highest tiers are brand-name and specialty drugs with the highest out-of-pocket cost. 

If Januvia does not appear in the formulary, work with your doctor to either consider an alternative or to appeal to your plan for an exception.

Resources

The American Diabetes Association website contains a wealth of information about the disease, including health tips and ideas for maintaining a nutritious diet. 

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