Does Medicare Cover Restasis?

Research suggests that roughly half of all adults in the United States suffer from symptoms of dry eye disease, according to an article published in the Ophthalmology Times. The condition occurs when your natural tears aren't enough to properly lubricate and protect your eyes. Tear production often slows due to aging and medical conditions, and allergies and certain medications can worsen symptoms.

People with dry eye disease are at an increased risk of eye infections and damage to the eyes that could pose a risk of vision loss. Fortunately, treatments can ease symptoms such as itching and redness and lower the likelihood of complications. Doctors frequently prescribe Restasis for the treatment of dry eye disease. Medicare often covers these prescription eye drops, making the cost of the drug more affordable.

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Does Medicare Cover Restasis?

GoodRx reports that 34% of Medicare prescription drug plans surveyed cover Restasis as of October 2023. If you're enrolled in Original Medicare (Parts A and B), coverage falls under Medicare Part D. This portion of Medicare is optional. You must sign up for a plan through a third-party insurer to receive coverage for Restasis and other drugs.

What Does Restasis Do?

Restasis is an eye drop approved by the U.S. Food and Drug Administration (FDA) to treat dry eye disease that arises due to inflammation on the surface of the eyes known as the cornea. Typically, you administer the eye drop two times per day with doses at least 12 hours apart. The drug works by reducing inflammation. Over time, this allows the eye to begin producing more tears.

How Much Does Restasis Cost?

Allergan, the manufacturer of Restasis, reports that the retail price for a 30-day supply of Restasis is around $645 as of October 2023. Prices vary by geographic location and from pharmacy to pharmacy.

Is There a Generic for Restasis?

The generic name for Restasis is cyclosporine. The FDA approved cyclosporine for sale in the United States in 2022.

How Much Will I Pay for Restasis With Medicare Part D?

With Medicare Part D, you'll typically have to pay a copay or coinsurance for Restasis. How much you're responsible for paying depends on how your plan classifies the medication and what stage of coverage you're currently at.

Laws require Medicare drug plans to cover at least one treatment for common medical conditions like dry eye disease; however, plans have the ability to choose which treatments they'll pay for.

Because Restasis doesn't have a generic alternative, your plan will likely classify it as a Tier 3 or 4 drug. You usually pay a higher copay for drugs in these tiers than you do for Tier 1 and 2. Copay amounts for Restasis vary widely from plan to plan. 

Does Medicare Part C Cover Restasis?

Some Medicare Part C or Medicare Advantage Plans include prescription drug coverage. If your plan provides the benefit, you'll need to consult the plan's formulary to find out if Restasis is covered. You'll usually have to pay a copay or coinsurance for covered drugs under Medicare Advantage.

Is There a Substitute for Restasis?

Cequa is another brand name version of cyclosporine. The cost of Cequa may be more or less than Restasis, depending on your plan's formulary.

Can I Get Help Paying for Restasis?

If you have Medicare Part D, you may be able to get help paying for premiums, deductibles and copays through the Extra Help program. The program is available for married Medicare enrollees whose net worth is $33,240 or less and for single Medicare enrollees whose net worth is $16,660 in 2023. Allergan states that most people who qualify for the Extra Help program pay less than $10 per month for Restasis as of October 2021.