Does Medicare Cover Tobi?

The costs of medications used to treat complications associated with cystic fibrosis can soon rack up. Fortunately, adequate healthcare insurance can help ease the strain on your wallet. This guide explains Medicare coverage for Tobi, including restrictions and out-of-pocket costs. 

What Is Tobi?

Tobi is a branded version of tobramycin, a type of antibiotic. Generic tobramycin comes in several forms, but Tobi is an inhaled medication used to treat bacterial lung infections in people with cystic fibrosis.

You take Tobi via a compressor to inhale the medication into your lungs. The drug comes in plastic ampules, each containing a single dose. You'll usually need to take Tobi last if you take other inhaled medications. 

Your Tobi dosage depends on several factors, including your age, health status and infection type. Therefore, your doctor will explain how often to take Tobi and how much to use. A typical course of treatment lasts around 28 days, and most people require two doses per day. 

Tobi Side Effects

You should consult your doctor as soon as possible if you experience unwanted side effects while taking Tobi. Potential side effects include:

• Nose bleeds
• Breathing difficulties
• Voice changes
• Congestion and sneezing
• Tinnitus and hearing loss
• Sore throat
• Fever

Does Medicare Cover Tobi?

Medicare Parts A and B don't usually cover Tobi, although exceptions may apply if your doctor administers the medication in an inpatient or outpatient setting. However, most people administer Tobi themselves at home, making their medication ineligible for coverage through Original Medicare. 

You can purchase a supplementary Medicare Part D plan to cover the costs of prescription drugs. Fortunately, around 95% of Medicare Part D plans cover Tobi. Your plan's formulary (list of covered drugs) can help you determine whether you're covered for Tobi, which usually appears under Tier 5. 

If your policy doesn't cover Tobi, ask your doctor if they can recommend a generic alternative. All Medicare Part D plans cover generic tobramycin.

How Much Will I Pay for Tobi With Medicare?

You'll need to pay the cost of your Tobi prescription yourself until you meet your annual Part D deductible. The legal limit for Part D deductibles is $545 in 2024, although some plans may charge lower or zero deductibles. 

Tobi is an exceptionally expensive medication, costing around $3,793.83 for a carton of 56 300-milligram ampules. In practice, this means that you'll meet the deductible on your first prescription and contribute no more than $480 towards the cost, plus co-pays charged by your insurer. Co-pays vary widely between providers, and you should expect to pay between $1 and $480 every time you receive coverage. 

Does Medicare Impose Tobi Restrictions?

As Tobi is so costly, your insurer may impose restrictions on your Medicare coverage. Some providers ask for prior authorization, meaning your doctor must contact the insurance company to explain why your medication is medically necessary. Your insurer may also limit the quantity of medication you can receive at one time.