Does Medicare Part D Cover Effient?
Yes — Effient (Prasugrel) is covered under Medicare Part D, filled by 98,000 beneficiaries across 864,000 claims in the latest year. It typically sits on tier 2 (preferred brand) of standard Part D formularies. Typical copay: $25-$50 per fill on most Medicare Part D plans.
Effient Medicare Coverage & Out-of-Pocket Cost
Effient is covered under Medicare Part D, with the program paying an average of $142 per prescription fill. Effient typically falls on Tier 2 (preferred brand) of standard Part D formularies. Typical copay: $25-$50 per fill on most Medicare Part D plans.
Your actual out-of-pocket cost depends on three factors: (1) formulary tier — your plan's specific placement; (2) deductible status — most plans require you to meet up to a $590 deductible (2025) before copays kick in; (3) coverage phase — initial coverage, then the donut hole was eliminated in 2025, replaced by a hard $2,000 annual out-of-pocket cap under the Inflation Reduction Act. Once you hit $2,000 in true out-of-pocket spending, the rest of your Part D drugs are free for the year.
Because generic Prasugrel is available, the single biggest savings move is asking your pharmacist about generic substitution. Generics typically sit on Tier 1 with copays under $10, vs Tier 2-3 placement for brand-name Effient. Most states allow automatic substitution unless your prescriber writes "dispense as written."
For cash-pay or commercial insurance scenarios, compare prices using GoodRx, SingleCare, or Cost Plus Drugs before filling — discount-program prices sometimes beat Part D copays for lower-cost generics.
How to Confirm Effient Coverage & Handle a Denial
Medicare Part D coverage of Effient is set plan-by-plan, not nationally. To confirm your plan covers it, look up Effient in the Medicare Plan Finder or your plan's online drug list, and check three flags: the formulary tier (drives your copay), prior authorization (PA), and step therapy (ST) or quantity limits.
Effient is a lower-cost drug, so it usually sits on a preferred tier with few restrictions — but always verify, since formularies change every plan year. If your plan denies coverage, you have the right to a formulary exception: your prescriber submits a statement of medical necessity, and the plan must respond within 72 hours (24 hours if expedited).
A denial can be appealed through five levels — redetermination by the plan, an independent review entity, an Administrative Law Judge, the Medicare Appeals Council, and finally federal court. Coverage resets every January, so re-check Effient on your formulary during open enrollment (October 15 – December 7) even if it was covered this year.
Key Facts: Effient Cost
- Medicare Part D avg
- $142/claim
- Likely Part D tier
- Tier 2 (preferred brand)
- Annual cost/patient
- $1,255
- Generic available
- Yes — Prasugrel
- Manufacturer
- Eli Lilly
- Treats
- Blood Clots
- YoY price change
- -18.6%
Source: CMS Medicare Part D Spending Dashboard. Tier placement inferred from typical formulary norms — confirm with your specific Part D plan.
Effient is manufactured by Eli Lilly and prescribed primarily for Blood Clots. In the most recent Medicare Part D data, 864,000 claims were filed for 98,000 unique beneficiaries, at an average cost of $142 per claim. Average annual cost per beneficiary is $1,255.
Year over year, Medicare spending on Effient has decreased by -18.6%. Because a generic version of Prasugrel is available, patients can often substitute to reduce out-of-pocket costs. Its patent expires 2023-01-31.
Key Data
| Metric | Value |
|---|---|
| Avg Cost Per Claim | $142 |
| Total Medicare Spending | $123.0M |
| Total Claims | 864,000 |
| Beneficiaries | 98,000 |
| Generic Available | Yes |
| Year-Over-Year Change | -18.6% |
Other Drugs for Blood Clots
Frequently Asked Questions
Yes. Effient appears in Medicare Part D claims data, with 98,000 beneficiaries filling 864,000 prescriptions in the latest year. Whether your specific plan covers it depends on that plan's formulary, so confirm on your plan's Summary of Benefits.
It can. Many Part D plans apply prior authorization, step therapy, or quantity limits to Effient. Prior authorization means your prescriber must document medical necessity before the plan pays. Check your plan's formulary "PA," "ST," or "QL" flags, or ask your pharmacist to run a test claim.
You have appeal rights. Start with a coverage determination / formulary exception request from your plan (your prescriber submits a supporting statement). If denied, you can escalate through five levels: redetermination, an independent review entity, an Administrative Law Judge, the Medicare Appeals Council, and federal court. Expedited 72-hour decisions are available when waiting could jeopardize your health.
Most Medicare Advantage plans include Part D drug coverage (MA-PD), so Effient is generally available — but each Advantage plan sets its own formulary, tier, and pharmacy network. Coverage and copay can differ from Original Medicare plus a standalone Part D plan, so compare the specific plan's drug list before enrolling.
Effient is typically placed on Tier 2 (preferred brand) of standard Part D formularies. Typical copay: $25-$50 per fill on most Medicare Part D plans. Your exact tier and cost-sharing are set by your individual plan and can change each plan year.
Use the Medicare Plan Finder at medicare.gov, enter Effient, and review each plan's formulary, tier, and restrictions. You can also call the number on your insurance card or check the plan's online drug lookup. Coverage is reset every January, so re-check during open enrollment (Oct 15 – Dec 7).
More about Effient
Yes — Effient (Prasugrel) is covered under Medicare Part D, filled by 98,000 beneficiaries across 864,000 claims in the latest year. It typically sits on tier 2 (preferred brand) of standard Part D formularies. Typical copay: $25-$50 per fill on most Medicare Part D plans.
The data source behind this answer is CMS Medicare Part D Drug Spending data. Every figure on the page traces back to that source; the methodology page describes the inputs and the refresh cadence in full detail.
A practical caveat: the headline answer above reflects the most recent CMS Medicare Part D Drug Spending data vintage; underlying data is often revised for months after first publication, and the right reference for any specific decision is whichever vintage is current at the time of the decision. The as-of date is stamped on every page.
Source: CMS Medicare Part D Spending, 2026.