Does Medicare Cover Plavix?

Plavix is an affordable medication, but many people have to take it for extended periods. The cost of using Plavix can become significant over time. Understanding whether Medicare covers Plavix and how much you'll pay out of pocket can help you manage the costs of your treatment.

What Is Plavix?

Plavix is a branded medication containing the generic clopidogrel. Clopidogrel works by preventing blood platelets from clumping together and causing blood clots.

Doctors use clopidogrel to prevent health conditions affecting the heart and blood vessels, such as strokes and heart attacks. Your healthcare provider may recommend taking Plavix or another clopidogrel medication if you've previously experienced a heart attack or stroke or have peripheral arterial disease, a condition that affects the blood supply to the legs. 

The most common Plavix dosage is a single daily tablet, with or without food. Plavix only works as long as you continue using it as prescribed by your doctor, so you should only stop taking your medication on your healthcare provider's advice. 

Plavix converts to a usable form inside your body, and the ability to convert Plavix varies from person to person. Therefore, it won't be an effective treatment for everyone. Your doctor may recommend a test to determine how your body reacts to Plavix to decide how much medication you should take. 

Plavix Side Effects

Occasionally, Plavix can cause side effects. You should tell your doctor immediately if you experience severe side effects or side effects that don't improve over time. Plavix side effects may include:

• Tiredness
• Headache
• Feeling or being sick
• Diarrhea
• Stomach pain
• Dizziness
• Nosebleeds

Does Medicare Cover Plavix?

Original Medicare restricts prescription drug coverage to a limited range of doctor-administered medications. Therefore, it's unlikely to cover Plavix because most people administer this medication at home. 

You're significantly more likely to receive Medicare coverage for Plavix if you purchase a supplemental prescription drug plan (Part D). These policies are available through private medical insurers approved by Medicare. 

All Medicare Part D plans cover Plavix or generic clopidogrel. You can determine which version your policy covers by checking the formulary, which is your insurer's list of covered drugs. Plavix and similar alternatives are relatively inexpensive, so they typically appear under Tier 1. 

How Much Does Plavix Cost With Medicare?

Medicare Part D only covers Plavix after you meet your deductible, although some insurers don't charge deductibles. Deductible-free plans usually cost significantly more per month than regular policies. The maximum annual deductible your provider can set is $545 in 2024 ($505 in 2023).

Before meeting your deductible, you'll need to pay for your Plavix prescription out of pocket. Prices for Pravix are relatively low, and you should expect to pay around $59.25 on average for 30 tablets at 75 milligrams each. Subscribing to a service that provides medication discount vouchers can significantly lower the cost of Plavix and similar drugs. 

Some Medicare Part D plans charge a small co-pay every time you collect a prescription after meeting your deductible. Your insurer then pays the balance of the cost of your medication. Co-pays for Plavix are usually nominal, with most insurance providers charging $1 or less per prescription. Furthermore, some plans have zero co-pays for drugs containing clopidogrel.

Does Medicare Restrict Plavix Coverage?

Medicare coverage restrictions for Plavix and similar drugs are relatively unusual. Most insurers don't ask for prior authorization from a healthcare provider, which means your doctor doesn't need to verify that your medication is medically necessary. Furthermore, your insurer is unlikely to place quantity restrictions on how much medication you can receive per prescription.