Expensive & Poorly Covered Medicare Medications
A Guide for Seniors: Common Prescriptions with Limited Part D & Advantage Plan Coverage
💊 Cardiovascular & Cholesterol Drugs
| Medication | Common Use | Why It's Expensive / Limited Coverage |
|---|---|---|
| Repatha (evolocumab) |
High cholesterol | Injectable biologic; usually Tier 4-5; often requires prior authorization. |
| Praluent (alirocumab) |
High cholesterol | Similar to Repatha; rarely covered under basic drug plans. |
| Entresto (sacubitril/valsartan) |
Heart failure | High-tier brand; coverage varies; often high copay even with insurance. |
| Eliquis (apixaban) |
Blood thinner (AFib) | Extremely common but expensive; copays often $100+; coverage varies widely. |
| Xarelto (rivaroxaban) |
Blood thinner (AFib, DVT, PE) | Brand-only; similar coverage issues as Eliquis. |
🧠 Neurology / Alzheimer's / Parkinson's
| Medication | Common Use | Coverage Challenges |
|---|---|---|
| Namenda XR (memantine ER) |
Alzheimer's disease | Extended-release form often excluded or high-tier. |
| Aricept (donepezil) |
Alzheimer's | Generic covered, but brand version not. |
| Rytary (carbidopa/levodopa ER) |
Parkinson's disease | Extended-release capsule form expensive; prior auth common. |
| Neupro (rotigotine patch) |
Parkinson's / restless legs | Patch form very costly; limited coverage. |
| Nuedexta (dextromethorphan/quinidine) |
Pseudobulbar affect (emotional outbursts) | Brand only; extremely high copay. |
🌿 Diabetes & Weight-Related Medications
| Medication | Common Use | Coverage Challenges |
|---|---|---|
| Ozempic (semaglutide) |
Type 2 diabetes / weight loss | Often excluded for "weight loss" use; shortages increase price. |
| Mounjaro (tirzepatide) |
Type 2 diabetes | Similar issues; new drug, limited formulary coverage. |
| Jardiance (empagliflozin) |
Diabetes & heart failure | Brand only; typically Tier 3-4. |
| Farxiga (dapagliflozin) |
Diabetes | Brand only; high copays. |
| Trulicity (dulaglutide) |
Diabetes | Injectable, popular, but often Tier 4 with $100+ monthly copay. |
🦴 Bone Health / Osteoporosis
| Medication | Common Use | Coverage Challenges |
|---|---|---|
| Prolia (denosumab) |
Osteoporosis | Administered in doctor's office; covered under Part B, but large coinsurance applies. |
| Forteo (teriparatide) |
Severe osteoporosis | Injectable; $3,000+/month retail; Part D rarely covers without exception. |
| Evenity (romosozumab) |
Osteoporosis | Injectable biologic; typically Part B, high coinsurance cost. |
🌬️ Respiratory (COPD / Asthma)
| Medication | Common Use | Coverage Challenges |
|---|---|---|
| Trelegy Ellipta | COPD / asthma | Popular inhaler, but $500+ retail; Tier 3-4 copay common. |
| Breo Ellipta / Anoro Ellipta | COPD | Similar high-tier brand inhalers. |
| Spiriva Respimat | COPD | Still expensive; coverage varies. |
| Daliresp (roflumilast) |
COPD flare prevention | Brand only; high copay, limited formulary inclusion. |
💥 Autoimmune / Rheumatology / Inflammation
| Medication | Common Use | Coverage Challenges |
|---|---|---|
| Humira (adalimumab) |
Rheumatoid arthritis, Crohn's | One of the highest-cost biologics; biosimilars now emerging but coverage inconsistent. |
| Enbrel (etanercept) |
Arthritis | Brand-only, injection; very high tier. |
| Xeljanz (tofacitinib) |
Rheumatoid arthritis | Oral biologic; often Tier 5. |
| Cosentyx / Stelara / Skyrizi | Psoriasis / psoriatic arthritis | Specialty-tier drugs; typically $1,000-$3,000 monthly even with insurance. |
💤 Sleep / Anxiety / Mood
| Medication | Common Use | Coverage Challenges |
|---|---|---|
| Belsomra (suvorexant) |
Insomnia | Often excluded from formularies; "lifestyle drug" classification. |
| Lunesta (eszopiclone) |
Insomnia | Generic available, but brand excluded. |
| Viibryd (vilazodone) |
Depression | Brand-only; few Part D plans cover. |
🧾 Pain Management / Nerve Pain
| Medication | Common Use | Coverage Challenges |
|---|---|---|
| Lyrica (pregabalin) |
Nerve pain, fibromyalgia | Generic available but still pricey; brand excluded. |
| Horizant (gabapentin enacarbil) |
Restless leg / nerve pain | Rarely covered. |
| Butrans Patch (buprenorphine) |
Chronic pain | Expensive transdermal patch; many Part D plans exclude it. |