Will Medicare cover my blood tests for Pradaxa?

1 answer | Last updated: Oct 03, 2016
Richard guth asked...

I was on Warfin. When Pradaxa came on the market I switch to it. Warfin required a blood test each month (paid by MEDICARE). My MD tells me that MEDICARE will not pay for the required blood tests for PRADAXA which are PTT, ECT, TT. Can you determine if these blood tests will be covered by MEDICARE.

Expert Answers

The Federal Drug Administration (FDA) approved Pradaxa in the Fall of 2010 as an anti-clotting ("blood thinning") agent that can replace Warfarin for some patients. Unfortunately, although the FDA approved Pradaxa, Medicare did not immediately list Pradaxa as a drug to be covered by Medicare Part C or Part D prescription drug plans, and so no Medicare drug plan included Pradaxa in its "formulary" of approved drugs (the drugs a plan will cover). And since no Medicare plan covered Pradaxa, Medicare Part B would not cover blood tests for it. In other words, because Medicare did not cover the drug itself, it would not cover testing that was done exclusively to see if that specific drug should be taken.

In April, however, Medicare approved Pradaxa for coverage, and some Medicare Part C and Part D prescription drug plans have begun to include it on their formulary. Because the drug itself is now approved by Medicare, Medicare Part B should now begin to cover regular blood tests required for someone who takes the drug. So, go back to see your doctor (who is probably aware that Medicare now covers the drug) and ask that he or she now submit a request to Medicare Part B to have your Pradaxa blood tests covered. Remember, though, that coverage for the medicine itself (rather than the blood tests) depends on the particular Medicare Part C Medicare Advantage plan, or Medicare Part D prescription drug plan, that you are enrolled in. The drug itself will only be covered if it is included in your plan's formulary list of covered drugs.