Does Medicare Cover Januvia or Trulicity?

Medicare Benefits Solutions
Nov 15, 2021

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.” 

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What is 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.

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Benefits and Risks of Januvia

Januvia is a prescription drug that treats Type 2 diabetes. 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.

What are the common side effects associated with Januvia?:

  • 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, contact your doctor immediately.

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Medicare Part D Januvia Benefits

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.

Managing Type 2 Diabetes with Trulicity

You may be able to control Type 2 diabetes, with the support of your health care provider or medical team, by following these CDC guidelines:

  • Maintain a nutritious diet and fitness program.
  • Monitor your blood pressure and cholesterol.
  • Test and track your blood sugar levels on an ongoing basis.
  • Find ways to reduce stress, including sleep and relaxation techniques.
  • Visit with a diabetes educator for support and guidance.
  • Be alert to changes in your vision, skin, and feet. 

In addition to these behaviors, your doctor may prescribe insulin or other medication. Trulicity is a drug designed to lower blood sugar levels. Doctors also prescribe the drug to reduce the risk of a heart attack or stroke in patients who have Type 2 diabetes coupled with heart disease or high-risk factors for cardiovascular disease. 

Trulicity is administered by weekly, self-administered subcutaneous (beneath the skin) injections. Part B Medicare benefits cover some injectable drugs. This typically applies to drugs a doctor would give you in the doctor’s office or, on a limited basis, in a hospital outpatient center. Part D Medicare benefits cover self-administered drugs.

How Much Does Trulicity Cost with Medicare?

You can get drug coverage through a Medicare Prescription Drug Plan or a Medicare Advantage plan with prescription drug coverage (MA-PD) when you become eligible for Medicare benefits. The stand-alone plan requires that you have either Part A or Part B, or both. The prerequisite for an MA-PD plan is enrollment in Part A and Part B. 

Most Part D Medicare plans cover the cost of Trulicity. The plan you join will provide access to a formulary, the list of drugs covered under your plan. Search for Trulicity to be sure the medication is covered. If the drug is listed, here are the factors to look for to understand your Medicare benefits:

  • Tier (You will most likely find Trulicity in Tier 3, preferred brand drugs.)
  • Requirements, such as mail-order delivery or prior authorization
  • Quantity limits

Medicare benefits for prescription drugs have a cost-sharing requirement. Your cost depends on:

  • Drug tier and associated coinsurance or copayment
  • Deductible, if applicable
  • Coverage stage: initial, gap, or catastrophic coverage

Type 2 Diabetes Resources

If you have Type 2 diabetes, your body is not effectively using the insulin it produces. This is a condition you can manage, according to the American Diabetes Association.  

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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