Does Medicare cover Clozaril?

If you have schizophrenia, finding the right treatment can help you enjoy better health and a more fulfilling life. However, the cost of the drugs used to treat schizophrenia can be an obstacle for many people. This guide explores Medicare coverage for Clozaril and other clozapine medicines. 

What Is Clozaril?

Clozaril is a branded version of clozapine. Doctors sometimes prescribe clozapine to treat severe schizophrenia when other drugs haven't worked. This medicine alters levels of certain brain chemicals to ease the symptoms of schizophrenia.

Clozaril comes as a tablet, disintegrating tablet or suspension liquid. It's highly restricted because it can cause complications. You may have to sign documents verifying that you understand the potential side effects. Clozaril interacts with some drugs. It's essential to tell your doctor if you take other medications, so they can determine whether Clozaril is safe for you. 

You can usually take Clozaril with or without food, and your doctor will decide the best dosage. Suddenly stopping your medication can cause your symptoms to return, so you should consult your doctor if you want to stop taking Clozaril. Often, healthcare providers recommend tapering the dose to prevent a relapse. 

Clozaril Side Effects

Clozaril can cause problems without noticeable symptoms, so your healthcare provider may perform regular blood tests to monitor your health. Seek medical care right away if you experience severe side effects, which could include:

• Infections
• Seizures
• Coordination problems
• Sleepiness
• Blurred vision
• Abnormal heartbeat
• Fainting
• Stomach problems such as vomiting or nausea
• Too much or too little saliva
• High blood sugar in people with diabetes

Does Medicare Cover Clozaril?

Medicare Parts A and B won't cover Clozaril in most circumstances because Original Medicare doesn't usually cover prescribed medications. However, it's possible that Original Medicare may cover Clozaril when administered by a healthcare provider in a hospital or outpatient setting. 

Medications containing clozapine are antipsychotics, which is a category of protected drugs. All Medicare Part D providers must cover the six protected drug classes. Therefore, 100% of Medicare supplemental prescription drug plans cover clozapine, although they may not cover the Clozaril brand.

All Medicare Part D policies include a formulary — a comprehensive list of all prescription medications covered by the plan. Drugs containing clozapine, including Clozaril, usually appear under Tier 2. You can consult the formulary to check if Clozaril is included. 

Your plan must cover clozapine in some form, so you can check for alternatives if your plan doesn't cover the brand prescribed by your doctor. Alternative versions of Clozaril include:

• Generic clozapine
• FazaClo
• Versacloz

How Much Does Clozaril Cost With Medicare?

Your Medicare Part D deductible depends on your provider, although it cannot exceed $545 in 2024 and $505 in 2023. Most Medicare insurance plans require you to pay full price for your medicine until you meet the deductible.

Every time you pay in full for prescription medications, the bill is subtracted from your deductible. Once you've met your deductible, Medicare starts to pay for your medications. This means that at first, you'll pay the same amount for Clozaril as you would without insurance. Clozaril costs around $199.35 for 90 tablets of 100 mg each. 

After meeting your deductible, you'll contribute a small copay every time you purchase Clozaril. Most Part D insurers charge Clozaril copays between $1 and $3.

Medicare Coverage Restrictions for Clozaril

Medicare Part D insurers usually restrict how much Clozaril you can buy because it can have severe side effects. These restrictions mean you can only receive a certain amount of your medication at any one time.