Does Medicare Cover Pramipexole?

If you have Parkinson’s Disease, your physician may prescribe pramipexole, often in combination with other drugs, to combat shaking, stiffness, balance problems and other symptoms of the condition. The drug may also be used to treat restless leg syndrome. Medicare beneficiaries taking this drug for either condition may find it helpful to understand the program’s coverage rules before filling a prescription.

What Is Pramipexole and How Is It Used?

Pramipexole is an oral medication that helps control symptoms of Parkinson’s Disease, restless leg syndrome and other disorders that cause unwanted movements. Often sold under the brand name Mirapex, the drug is classified as a dopamine agonist because it mimics the actions of natural dopamine, a neurotransmitter that’s often absent in individuals with these diseases. When taken regularly, pramipexole promotes normal dopamine activity, reducing tremors, restoring muscle control, minimizing muscle spasms and limiting unwanted movements.

Dosing of pramipexole typically depends on what disease the drug is being used to treat and whether it's administered through regular or extended-release tablets. For maximum effectiveness, this medication should be taken exactly as prescribed.

Does Medicare Cover Pramipexole?

All Medicare prescription drug plans cover pramipexole. However, only beneficiaries enrolled in either a Part D prescription drug plan or a bundled Medicare Advantage policy that includes prescription drug coverage receive this benefit. 

What Is Medicare’s Out-of-Pocket Cost for Pramipexole?

Depending on your plan, you may not have to pay anything for pramipexole or your co-pay may be as high as $20. Out-of-pocket costs may be impacted by your policy's deductible and what stage of coverage you're in.

How Deductibles Affect Cost

Prior to meeting your Medicare deductible, you may have to pay the full retail cost of the medication. Although deductibles vary by plan, Medicare sets limits, and in 2024, a plan's deductible may not exceed $545. However, some policies may waive the deductible requirement for certain tiers of drugs.

Medicare’s Donut Hole

Seniors who have substantial prescription drug costs may enter Medicare’s donut hole, a coverage gap that occurs when the total drug costs paid by the plan and enrollee combined pass a yearly threshold. In 2024, beneficiaries entered the donut hole when the total cost of prescription medications hit $5,030. Seniors who are in Medicare’s donut hole are typically responsible for paying a larger percentage of a drug’s cost.

Catastrophic Coverage

Beneficiaries with substantial medical expenses may eventually pass out of the donut hole into their plan’s catastrophic coverage phase. Seniors who’ve reached their policy’s maximum out-of-pocket limit and enter the catastrophic coverage phase receive full coverage for their prescription medications going forward.

Can Medicare Limit the Number of Pills You Get?

If your plan has a coverage limit for a particular drug, Medicare may restrict the number of pills it pays for. Beneficiaries who are prescribed more medication than permitted under Medicare may be responsible for the cost. Your plan administrator can help you understand the terms of your individual policy and how it affects your out-of-pocket costs. 

How Can You Get Prescription Drug Coverage Through Medicare?

Medicare beneficiaries may obtain prescription drug coverage, which can help them pay for medications, such as pramipexole, by either:

• Purchasing a Part D prescription drug plan: Original Medicare participants who have Parts A and/or B may purchase an optional Part D plan, which provides prescription drug benefits. Once enrolled in a Part D plan, seniors receive coverage for any medication listed in their policy’s formulary. Drugs are typically organized into tiers, and higher-tier drugs may have higher co-pays than lower-tier medications. If a drug isn’t listed in the formulary, check with your plan administrator because a similar medication may be covered, or you may be able to file an appeal.
  
  
• Purchasing a bundled Part C policy: Most Medicare Advantage plans, also known as Medicare Part C, have prescription drug coverage bundled in. Some policies, such as special needs plans, even require insurers to provide this benefit. These plans also have tiered formularies that group prescription medications by cost. However, it’s important to note that if the Part C plan you choose doesn’t include prescription drug benefits, you typically can’t purchase a separate Part D policy for coverage. 

How Much Does Pramipexole Cost Without Insurance?

Without prescription drug coverage, pramipexole prices vary widely by pharmacy and prescribed dose. However, for comparison, the cost for a 90-day supply of 0.25-milligram oral tablets is typically around $29.

Can You Lower Your Costs for Pramipexole?

Medicare beneficiaries may be able to lower the cost of pramipexole and other prescription drugs by:

• Applying for a patient assistance program: Drug manufacturers often offer subsidy programs that provide prescription medications to low-income individuals for free or at a reduced cost. These cost assistance programs typically have strict income limits, and many require a physician to fill out and submit the application.
  
  
• Purchasing a 90-day supply: By purchasing a longer supply of a prescription drug, seniors may be able to reduce their overall out-of-pocket cost. Some plans may require enrollees to purchase a 90-day supply through a mail-order affiliate.
  
  
• Requesting a government subsidy: The federal Extra Help program, which is officially known as the Part D Low-Income Subsidy, provides assistance to seniors who need help covering the cost of prescription medications. To qualify, enrollees must participate in a Part D plan and meet the program’s income requirements.

Where Can You Get Medicare Counseling?

Because coverage guidelines and program requirements often change, Medicare counseling is often the best way for seniors to find ways to lower the cost of their prescription medications. Medicare counseling is often available at regional senior centers or through your local Area Agency on Aging.