Does Medicare cover Otezla in North Carolina?

What Otezla is used for

Otezla is a tablet; Otezla XR is a once-a-day extended-release version. Its FDA label covers plaque psoriasis, active psoriatic arthritis in adults, and mouth ulcers caused by Behçet's disease in adults.

This page explains Medicare coverage only. Questions about whether Otezla is right for you belong with your prescriber.

Which part of Medicare covers Otezla

Otezla is a pill you take at home, so it's a Part D drug. Medicare.gov explains that Part B usually covers drugs you wouldn't typically give yourself, like infusions in a doctor's office; Otezla isn't one of them, so there's no Part B piece. Plans may use step therapy, asking you to try other treatments first; your prescriber can request an exception if those aren't right for you.

Is Otezla on Medicare's negotiated-price list?

Yes. CMS selected Otezla and Otezla XR in the second round of the Medicare Drug Price Negotiation Program, and the negotiated price takes effect January 1, 2027. A negotiated price (the law calls it the "maximum fair price") is what Medicare drug plans and pharmacies pay; it isn't your copay. What you pay still depends on your plan's cost sharing. See Which drugs have Medicare negotiated prices in 2027?

Generics

There's no generic apremilast on the market. CMS can only select drugs without generic competition, and Otezla remains on its list.

What you pay for Otezla in 2027: the out-of-pocket cap

Your cost depends on your plan: its deductible, the tier it puts the drug on, and whether you use a preferred pharmacy. This site doesn't list plan costs; your plan's formulary and Evidence of Coverage do. What Medicare sets for everyone with Part D is the limit:

• 2027 out-of-pocket cap: $2,400 (it was $2,100 in 2026). Once what you pay for covered Part D drugs (deductible, copays and coinsurance) reaches the cap, you pay nothing more for covered Part D drugs for the rest of 2027.
• The maximum Part D deductible for 2027 is $700. No plan can set a higher one.
• Only covered drugs count. If your plan doesn't cover Otezla and you pay cash or use a discount card instead of your plan, that spending doesn't count toward the cap.

Spreading the cost: the Medicare Prescription Payment Plan

A brand-name drug taken every day can push you toward the cap early in the year. The Medicare Prescription Payment Plan, offered by every Part D plan and Medicare Advantage plan with drug coverage, replaces those pharmacy payments with monthly bills from your plan spread across the calendar year. Medicare.gov says there's no cost to participate, but it doesn't lower your drug costs; it only changes when you pay. To join, call your plan or use its website. More in What is the Medicare Prescription Payment Plan?

Extra Help with Otezla

Extra Help (the Low-Income Subsidy) is a federal program that lowers Part D premiums, deductibles and copays. For 2027, CMS caps Extra Help copays for covered drugs at $5.80 for a generic and $14.40 for a brand-name drug like Otezla, and some people with full Medicaid pay less. You get Extra Help automatically if you have full NC Medicaid, a Medicare Savings Program (North Carolina calls them MQB) or SSI. Otherwise, apply through Social Security at ssa.gov/extrahelp or 1-800-772-1213 (TTY 1-800-325-0778). See Extra Help in North Carolina.

Getting Otezla covered in North Carolina

North Carolina is a Part D region of its own (PDP Region 08), so each standalone Part D plan sold here is offered in all 100 counties. For 2027, CMS lists 11 standalone Part D plans from 6 companies in the state, and 106 Medicare Advantage plans open to everyone are offered across North Carolina. Each plan has its own formulary, so one plan's coverage of Otezla tells you nothing about another's.

No state drug program for seniors. North Carolina doesn't run a general state pharmaceutical assistance program for people on Medicare, so for most people the help with a brand-name drug's cost is federal: the Part D cap, the payment plan and Extra Help. See Does North Carolina have a prescription assistance program for seniors?

State Health Plan retirees. If you're in the State Health Plan's Base Plan or Enhanced Plan (group Medicare Advantage plans with Part D), Otezla is covered, or not, under the Plan's drug list. The Plan says joining an outside Part D or Medicare Advantage plan disenrolls you from its group plan and moves you to the 70/30 Plan. See State Health Plan retirees and Medicare.

Indian health care. CMS says that if you get prescriptions through an Indian health pharmacy, such as one run by the Indian Health Service or a tribe, you continue to get them at no cost to you when you join a Medicare drug plan, and the plan pays the facility. That care also counts as creditable drug coverage, so you don't owe a Part D late penalty if you join later. See American Indians and Medicare in North Carolina.

Medicare and NC Medicaid. If you have both, your Medicare drug coverage, not NC Medicaid, pays for Part D drugs like Otezla. If your Medicare Advantage plan ends in 2027, you have a special enrollment period through February 28, 2027; choose new drug coverage by December 31, 2026, to avoid a gap. See plans ending in 2027.

How to check whether a plan covers Otezla

1. Write down the exact drug. Otezla or Otezla XR, the strength and how often you take it.
2. Look it up in each plan's formulary. Enter your drugs and ZIP code on PlanMatch or Medicare.gov's Plan Finder to see which plans list Otezla and any rules.
3. Read the rules next to the drug. Prior authorization or step therapy means your prescriber may need to send the plan your history before it pays.
4. Check your 2027 notice. Your plan's Annual Notice of Change says whether Otezla stays on the formulary next year. Open Enrollment runs October 15 to December 7, 2026.
5. Get help if you want it. You can request a call from a licensed insurance agent, who can compare plans from the companies they work with, or call 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048) for information on all of your options.

If your plan doesn't cover Otezla, you or your prescriber can ask for a coverage determination or a formulary exception. Once the plan has your prescriber's supporting statement, it generally must decide within 72 hours, or 24 hours if waiting could seriously harm your health. See How do I appeal a Medicare denial in North Carolina?

Sources

• National Library of Medicine — DailyMed: Otezla prescribing information (FDA label)
• Medicare.gov — Drug coverage (Part D)
• Medicare.gov — Prescription drugs (outpatient) under Part B
• CMS — Selected drugs and negotiated prices (Medicare Drug Price Negotiation Program)
• CMS — CY 2027 Rate Announcement (2027 Part D out-of-pocket threshold, deductible and Extra Help copays)
• Medicare.gov — Medicare Prescription Payment Plan
• Social Security — Extra Help with Medicare prescription drug plan costs
• Medicare.gov — Your Guide to Medicare Drug Coverage (CMS Product 11109; Indian health pharmacies and creditable coverage)
• eCFR — 42 CFR 423.120 (formularies and transition fills)
• CMS — Prescription drug coverage (CY 2027 Landscape files: North Carolina is PDP Region 08)
• State Health Plan — Retiree presentation (group Medicare Advantage and outside Medicare plans)

Frequently asked questions

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