Medicare Part D covers most cardiovascular medications, but what you actually pay and how much effort it takes varies enormously by drug class. Generic statins can cost $0. PCSK9 inhibitors require extensive prior authorization and step therapy. GLP-1 receptor agonists may or may not be covered depending on why they’re prescribed.

This guide breaks down Medicare coverage for the four most important classes of cardiovascular medications in 2026, with the specific policies and programs that determine your costs.

How Medicare drug plans are structured (Part D)

Before diving into specific drugs, it helps to understand the Part D benefit structure that applies to all of them. The Inflation Reduction Act fundamentally redesigned Part D starting in 2025:

• Annual out-of-pocket cap: $2,100 in 2026 (up from $2,000 in 2025). After you hit this cap, you pay $0 for covered drugs the rest of the year.
• No more “donut hole”: The coverage gap was eliminated entirely as of January 1, 2025. The benefit now has three phases: deductible ($615 in 2026), initial coverage (you pay 25%), and catastrophic ($0).
• $35 insulin cap: Monthly cost-sharing for insulin capped at $35.
• $0 vaccines: All ACIP-recommended vaccines covered at $0.
• Medicare Prescription Payment Plan: Plans must offer monthly installment options to spread out-of-pocket costs.

The $2,100 OOP cap is the single biggest change for cardiovascular medication costs, especially for expensive drugs like PCSK9 inhibitors that previously pushed patients into the catastrophic phase with uncapped 5% coinsurance.

Statins are widely covered by Medicare

Generic statins are the easiest and cheapest cardiovascular medication to get through Medicare Part D. Generic atorvastatin, rosuvastatin, simvastatin, pravastatin, and lovastatin are universally covered by Part D plans. These statins are typically placed on Tier 1 (Preferred Generic) with copays of $0 to $10 per 30-day supply. Many plans now offer $0 copays for Tier 1 generic statins as a competitive benefit.

Brand-name statins, like Lipitor or Crestor, are on higher tiers with substantially higher copays.

No prior authorization or step therapy is required for generic statins. Your doctor writes the prescription, and your plan fills it.

No statins were selected for Medicare drug price negotiation since they’re already cheap generics.

Medicare coverage of Ezetimibe (generic Zetia)

Ezetimibe is widely covered, cheap, and has minimal hurdles. Generic ezetimibe has been available since 2016 and is covered by essentially all Part D plans. It’s typically placed on Tier 1 or Tier 2 with copays of $0 to $15 per month. The combination ezetimibe/simvastatin (generic Vytorin) is also available and similarly priced.

Some plans may require documentation that the patient hasn’t achieved LDL-C goals on maximally tolerated statin therapy, but this is not universal.

PCSK9 inhibitors (Repatha, Praluent)

PCSK9 inhibitors have some coverage in Medicare, but require extensive prior authorization and step therapy. The $2,100 OOP cap has made PCSK9 inhibitors more affordable for Medicare beneficiaries than before.

Approximately 90-95% of Part D plans cover PCSK9 inhibitors. PCSK9 inhibitors are placed on the Specialty Tier (Tier 5), the highest cost-sharing tier, with typical coinsurance of 25-33%. About 97% of plans that cover PCSK9 inhibitors require prior authorization, usually with fairly extensive criteria. For example, the insurer may require documentation that the patient hasn’t reached LDL-C goals on maximally tolerated statin therapy, a trial of ezetimibe added to statin (step therapy), and documentation from a cardiologist or lipid specialist (some plans). In practice, this means most patients must try and fail a statin plus ezetimibe before Medicare will approve a PCSK9 inhibitor.

Repatha’s list price is ~$573/month and Praluent is $488/month. Since your total annual out-of-pocket for all Part D drugs combined is capped at $2,100, for patients who take a PCSK9 inhibitor, this cap is typically reached in the first few months of the year. An alternative is the Amgen direct program for Repatha at $239/month through the AmgenNow program, bypassing insurer prior authorization entirely. This may be worth considering for patients who can’t get PA approval, or want to avoid the step therapy process, though it doesn’t count toward Part D’s OOP cap.

GLP-1 receptor agonists

GLP-1 receptor coverage depends on the indication: covered for diabetes, increasingly covered for cardiovascular risk reduction, still excluded for weight loss alone.

GLP-1s are the most complex coverage situation in cardiovascular medicine right now. The rules are changing rapidly, and what you’re prescribed the drug for determines whether Medicare will pay.

Covered: GLP-1s for type 2 diabetes

Ozempic (semaglutide), Mounjaro (tirzepatide), and Rybelsus (oral semaglutide) are covered under Part D when prescribed for type 2 diabetes. Tier placement varies (Tier 3-5); prior authorization is common.

Covered: GLP-1s for cardiovascular risk reduction

In March 2024, the FDA approved Wegovy (semaglutide) for cardiovascular risk reduction in adults with established cardiovascular disease (prior MI, stroke, or PAD) who are overweight or obese, based on the SELECT trial (20% reduction in major adverse cardiovascular events).

CMS issued guidance that Part D plans can cover Wegovy for this cardiovascular indication, because it’s a cardiovascular use — not an “obesity/weight loss” use subject to Medicare’s statutory exclusion. Approximately 3.6 million Medicare beneficiaries are potentially eligible.

Not covered: GLP-1s for weight loss/obesity

Medicare has a longstanding statutory exclusion (Social Security Act Section 1862(a)(1)(A)) prohibiting Part D coverage of drugs used for “anorexia, weight loss, or weight gain.” This blocks coverage of Wegovy, Zepbound, and Saxenda when prescribed solely for weight management.

Coming soon: BALANCE Model, drug price negotiation for GLP-1s

CMS announced the BALANCE Model (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) in December 2025, which creates a new pathway for GLP-1 coverage.

• Medicare GLP-1 Payment Demonstration (bridge program): Launches July 2026. Eligible beneficiaries pay $50/month for GLP-1 medications.
• Full BALANCE Model in Part D: Launches January 2027.
• Covered drugs: Mounjaro, Ozempic, Rybelsus, Wegovy, Zepbound KwikPen, and orforglipron (if FDA-approved).
• Eligibility: BMI 35+ (any qualifying condition), BMI 30+ with heart failure/hypertension/CKD, or BMI 27+ with pre-diabetes/prior MI/stroke/PAD — plus a qualifying condition (T2D, MASH with advanced fibrosis, or obstructive sleep apnea).

Ozempic, Rybelsus, and Wegovy were selected for the second round of Medicare drug price negotiation, with negotiated Maximum Fair Prices taking effect January 1, 2027:

Summary

Statins and other generic drugs have wide coverage in Medicare. For newer cardiovascular medications, the new $2,100 annual out-of-pocket cap is the single most important change. For patients on expensive drugs like PCSK9 inhibitors or GLP-1s, it transforms an open-ended cost into a predictable annual maximum.