Omeprazole and Medicare coverage

Medical News Today

5 days ago

Many Medicare Part D or Part C plans with drug coverage cover omeprazole when a doctor prescribes it. Some Part C plans may even allow a person to buy it over the counter.
Omeprazole can be purchased over the counter or with a prescription. However, over-the-counter (OTC) purchases typically cannot be made through a health insurance plan.
This article explores how people can use their Medicare Part D prescription plan or Medicare Advantage (Part C) plan with drug coverage to purchase prescription omeprazole and the potential out-of-pocket expenses individuals might encounter.
Is omeprazole covered by Medicare Part B?
However, Part B only covers medications a person cannot take themselves, such as IV drugs .
For this reason, omeprazole coverage falls under Part D. Studies indicate that many Part D plans cover this medication in its prescribed form.
In addition, some Part D plans may cover OTC omeprazole if a person has a doctor's prescription. What tier level is omeprazole?
Whether a person's specific plan covers the generic omeprazole or Prilosec brand depends on its inclusion in the plan's specific formulary.
Within this formulary, every Part D plan categorizes drugs into tiers. Generally, the higher the tier, the more a person will pay out of pocket even after Part D coverage kicks in.
While each Part D plan may place omeprazole in a different tier, more commonly prescribed or preferred drugs tend to feature in lower tiers. In addition, formularies are more likely to rank generic omeprazole lower than Prilosec.
However, it is essential to understand that certain Part D plans may require individuals to try the OTC version of a medication before approving coverage for the prescription form. This process is known as step therapy. Medicare Advantage
However, what is different about such Part C plans is that some may provide an additional benefit for OTC medications, allowing a person to buy the drug over the counter using their plan.
How much does omeprazole cost with Medicare?
The cost for thirty 40-milligram capsules of generic omeprazole fluctuates between $10 and $48, depending on the pharmacy dispensing it.
In contrast, the brand-name drug Prilosec, when a person acquires it under prescription, costs between $448 and $476, making it considerably more expensive than its OTC or generic alternatives.
The amount someone pays for prescription Prilosec or non-OTC generic versions after Medicare coverage takes effect depends on the drug's tier classification in their plan's formulary. Drugs in higher tiers typically incur higher costs.
Furthermore, Medicare Part C and D plans generally require meeting a deductible and paying a monthly premium, which varies by plan. In 2025, the national base beneficiary premium for Part D is $36.78, while the average monthly premium for Part C is around $17.
In addition, a person must still pay the Part B premium to enroll in a Part C plan. However, some plans may cover this cost.
What is the best alternative to omeprazole under Medicare?
Omeprazole falls into the drug category of proton pump inhibitors (PPIs) and is among the top ten prescribed medications in the United States.
That said, there are other PPIs, including:
Which of these drugs works best depends on the person, their specific health needs, and the doctor's recommendations.
It is also essential to know that not every PPI has approval for treating the same medical conditions. Medicare may not approve coverage if a doctor prescribes a drug off-label or for a reason the insurance does not consider medically necessary.