Does Medicare cover Repatha in North Carolina?

What Repatha is used for

Repatha is a PCSK9 inhibitor, an injectable biologic that lowers LDL ("bad") cholesterol. Its FDA label covers reducing the risk of heart attack, stroke and some heart procedures in certain adults, and lowering LDL cholesterol in certain adults and children with high cholesterol, including inherited forms, usually alongside diet and other cholesterol medicine.

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

Which part of Medicare covers Repatha

Repatha comes as a prefilled SureClick autoinjector or syringe that you use at home, so it's a Part D drug. Medicare.gov says Part B usually covers drugs you wouldn't typically give yourself, like those given in a doctor's office; Repatha isn't one of them. Plans commonly require prior authorization: your prescriber documents your diagnosis, LDL results and the treatments you've already tried.

Is Repatha on Medicare's negotiated-price list?

No. Repatha is not among the drugs CMS has selected for the Medicare Drug Price Negotiation Program so far: the 10 drugs with negotiated prices since January 1, 2026, the 15 with negotiated prices starting January 1, 2027, and the 15 CMS selected on January 27, 2026, for prices that take effect in 2028.

Biosimilars

Repatha is a biologic, so a lower-cost version would be a biosimilar rather than a generic. FDA's Purple Book lists any licensed biosimilars; ask your pharmacist what's available and on your plan's formulary.

What you pay for Repatha 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 Repatha and you pay cash or use a discount card, that spending doesn't count toward the cap.

Spreading the cost: the Medicare Prescription Payment Plan

The Medicare Prescription Payment Plan lets you pay your Part D drug costs in monthly bills from your plan across the calendar year instead of at the pharmacy. Every Part D plan and Medicare Advantage plan with drug coverage offers it. Medicare.gov says there's no cost to participate, but it doesn't lower your drug costs; it only changes when you pay. It helps most when costs are high early in the year. More in What is the Medicare Prescription Payment Plan?

Extra Help with Repatha

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 Repatha, 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). North Carolina has no general state drug-assistance program for seniors. See Extra Help in North Carolina.

Getting Repatha 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 every county has Medicare Advantage plans open to everyone, from 11 in Carteret County to 57 in Guilford County. Each plan has its own formulary and prior-authorization rules. Your county's numbers are on North Carolina counties.

Refrigerated medicine and power outages. Repatha is stored in the refrigerator. Its FDA label says that, if needed, it can be kept at room temperature (68 to 77 degrees Fahrenheit) in its original carton, but then must be used within 30 days. If a hurricane or ice storm knocks out your power and the medicine gets warmer than that, ask your pharmacist whether it's still usable; CMS says Medicare pays to replace prescription drugs damaged in a disaster. See hurricanes, floods and Medicare.

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), Repatha is covered, or not, under the Plan's drug list and its prior-authorization rules. 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.

Changing plans. A new plan usually needs its own prior authorization, so ask your prescriber to send it as soon as you enroll. 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. If you have Medicare and NC Medicaid, Medicare drug coverage pays for Repatha, not NC Medicaid. See plans ending in 2027.

How to check whether a plan covers Repatha

1. Write down the exact drug. Autoinjector or syringe, the dose and how often you inject.
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 Repatha and any rules.
3. Read the rules next to the drug. "PA" means prior authorization, and "ST" means step therapy; your prescriber may need to send lab results and treatment history.
4. Check your 2027 notice. Your plan's Annual Notice of Change says whether Repatha 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 denies Repatha, 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. New members can usually get a transition supply while they ask. See How do I appeal a Medicare denial in North Carolina?

Sources

• National Library of Medicine — DailyMed: Repatha prescribing information (FDA label, including storage)
• 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 — Selected drugs for initial price applicability year 2028 (fact sheet, January 2026)
• FDA — Purple Book: licensed biological products, biosimilars and interchangeables
• 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
• eCFR — 42 CFR 423.120 (formularies and transition fills)
• CMS — Prescription drug coverage (CY 2027 Landscape files: North Carolina is PDP Region 08)
• CMS — Replacing Durable Medical Equipment and Prescription Drugs after a Disaster
• State Health Plan — Retiree presentation (group Medicare Advantage and outside Medicare plans)

Frequently asked questions

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