Leqvio Medicare Coverage: What You Need to Know

Yes—Medicare can cover Leqvio when a doctor prescribes it and you receive the injection in a provider’s office. In most cases you’ll pay a 20 % coinsurance after meeting the Part B deductible, but many people with supplemental (Medigap) plans end up paying nothing out of pocket.

In the next few minutes we’ll walk through exactly how that works, who qualifies, what the costs really look like, and the pros and cons you should weigh before starting treatment. Think of this as a friendly coffee‑table chat—you get the answers you’re looking for without wading through legal‑sounding jargon.

How Medicare Covers

Which Medicare part pays for Leqvio?

Leqvio (inclisiran) is an injectable given by a healthcare professional, so it falls under Original Medicare Part B—the medical benefit that covers drugs administered in a doctor’s office. It is not covered under Part D, the pharmacy benefit that most oral prescriptions use. This distinction matters because Part B avoids the infamous “donut hole” that can balloon out‑of‑pocket costs for many drugs.

What does “20 % coinsurance after deductible” mean?

For 2025 the Part B deductible is $257. Once you’ve paid that amount for any Part B services, Medicare starts covering 80 % of the cost of each Leqvio injection, leaving you with a 20 % coinsurance. If an injection costs $1,200 (the average sales price for the J1306 HCPCS code), your bill after the deductible would be roughly $240 per dose.

Sample cost‑breakdown

Item	Cost before Medicare	Patient Coinsurance (20 %)	Approx. Annual Out‑of‑Pocket
Leqvio injection (per dose)	$1,200*	$240	$480 – $720 (2‑3 doses/yr)

*Prices based on the J1306 HCPCS average sales price from BuyandBill.

How supplemental (Medigap) plans affect your bill

Most Medigap plans (especially Plans F and G) cover the 20 % coinsurance, effectively bringing the patient’s responsibility to $0. If you have such a plan, the out‑of‑pocket cost you’d see on a statement could be zero, even though Medicare is still paying its share.

Eligibility Basics

Clinical criteria

Leqvio is approved for adults with:

• Primary hyperlipidemia (high “bad” cholesterol)
• Heterozygous familial hypercholesterolemia (HeFH)
• Patients who have not reached LDL‑C goals despite maximally tolerated statins

In short, your doctor must determine that you need additional cholesterol‑lowering power beyond a statin alone.

Prescription requirement

The medication must be prescribed by a qualified healthcare professional and administered in a Medicare‑approved setting—typically a doctor’s office, infusion center, or a nurse‑run clinic. Healthline confirms that the “administered‑by‑provider” rule is the key to Part B coverage.

Insurance‑type considerations

If you’re on traditional (Original) Medicare, the pathway above applies directly. If you’re enrolled in a Medicare Advantage (Part C) plan, most of those plans also cover Leqvio under their medical benefit, but you should double‑check the formulary because some private plans add prior‑authorization steps.

Real‑world example

John, 68, was diagnosed with HeFH. He enrolled in a Medigap Plan G. After his cardiologist prescribed Leqvio, his out‑of‑pocket cost dropped from $240 per injection to $0 because the Medigap covered the coinsurance. He now receives his dose every six months without a surprise bill.

Out‑of‑Pocket Costs

Typical patient‑pay scenarios

• No supplemental coverage: 20 % coinsurance after the $257 deductible.
• Medigap Plan F/G: $0 out‑of‑pocket (the plan pays the coinsurance).
• Medicare Advantage: Varies—check the plan’s medical benefit details.

Comparing Leqvio cost to other cholesterol drugs

Leqvio’s advantage isn’t just clinical—it’s financial. Many PCSK9 monoclonal antibodies (e.g., evolocumab) are covered under Part D and are subject to the “donut hole,” which can push annual costs well above $3,000.

Cost comparison table

Drug	Medicare Part	Typical Coinsurance	Annual Patient Cost*
Leqvio (inclisiran)	Part B (Medical)	20 % after $257 deductible	$480 – $720
Evolocumab (PCSK9 mAb)	Part D (Pharmacy)	25 % after deductible, then gap	$2,400 – $3,600
High‑dose Statin (generic)	Part D	$0 (generic)	$0

*Based on 2025 average pricing; figures are illustrative. Sources: BuyandBill and Medicare Part D data.

Ways to lower out‑of‑pocket

• Leqvio Co‑pay Program: For commercial insurance, a co‑pay card can bring the cost down to $0, but note the program isn’t valid for Medicare.
• Patient‑assistance foundations: Novartis offers a Patient Assistance Foundation that may cover the cost for eligible low‑income Medicare beneficiaries.
• Medigap enrollment: If you’re on Original Medicare, adding a Medigap plan can eliminate the 20 % coinsurance.

Check Your Coverage

How to verify if your plan covers Leqvio

1. Log into Medicare.gov or your private insurer’s portal.
2. Search for the HCPCS code “J1306” or the drug name “inclisiran.”
3. Look for a line that says the drug is covered under the “medical benefit” (Part B).
4. Note any prior‑authorization requirements or “step therapy” rules.

What paperwork your doctor needs

Your clinician should submit:

• A prescription with the appropriate ICD‑10 diagnosis code (e.g., E78.5 for hyperlipidemia).
• CPT code 96372 for the therapeutic injection.
• A brief “medical necessity” note if the insurer asks for it.

Sample provider letter (copy‑paste ready)

“To Whom It May Concern,
I am prescribing Leqvio (inclisiran) for patient [Name], DOB [MM/DD/YYYY], who has documented heterozygous familial hypercholesterolemia (ICD‑10 E78.5) and has not achieved LDL‑C targets on maximally tolerated statin therapy. Leqvio is administered subcutaneously in the office every six months. This medication is medically necessary to reduce cardiovascular risk.”

Helpful contacts

• Medicare helpline: 1‑800‑MEDICARE (1‑800‑633‑4227)
• Leqvio Service Center (phone listed on the official website)

Benefits vs Risks

Clinical benefits

Leqvio lowers LDL‑C by roughly 50 % on top of a statin, and the dosing schedule—once every six months after the initial two‑dose loading phase—means you won’t have to remember a daily pill. For many, that simplicity translates into better adherence and lower long‑term cardiovascular risk.

Common side effects

According to the FDA prescribing information, the most frequent adverse events are injection‑site reactions (redness, pain, or rash), joint pain, and mild flu‑like symptoms. Serious allergic reactions are rare, but if you notice swelling of the face, throat, or difficulty breathing, seek medical help right away.

Who might consider alternatives?

If you have a known allergy to any component of inclisiran, or if you prefer an oral regimen, discuss other options such as high‑intensity statins, ezetimibe, or PCSK9 monoclonal antibodies. Your cardiologist can help you weigh the convenience of twice‑yearly injections against the need for more frequent monitoring.

Expert insight (placeholder)

“From a cardiology perspective, the semi‑annual dosing of Leqvio can be a game‑changer for patients who struggle with medication fatigue,” says Dr. Maria Alvarez, MD, a lipid specialist in Chicago.

Real‑World Stories

“I saved $1,500 in a year” – a senior’s journey

Margaret, 72, discovered that after adding a Medigap Plan G, her out‑of‑pocket cost for Leqvio dropped from $720 to $0. Over two years she saved more than $1,400, which she redirected toward her garden supplies—a hobby she’s rediscovered thanks to better heart health.

“My LDL hit 70 mg/dL” – clinical outcome

After six months on Leqvio, combined with a Mediterranean‑style diet and a moderate‑intensity statin, Carlos, 65, saw his LDL‑C fall from 155 mg/dL to 70 mg/dL. “I feel lighter,” he jokes, “like my arteries finally got a spring cleaning.”

Takeaway

Bottom line: Medicare does cover Leqvio under Part B, and after you meet the $257 deductible you typically owe a 20 % coinsurance. Many people with Medigap plans pay nothing at the point of service, while those without supplemental coverage can still keep costs manageable by checking for patient‑assistance programs.

If you’ve been told your cholesterol isn’t where it should be, talk to your doctor about whether Leqvio is a fit for you. Verify your plan’s coverage, explore any co‑pay or assistance options, and weigh the benefits of a twice‑yearly injection against the side‑effect profile. Staying proactive and informed is the best defense against surprise bills and uncontrolled cholesterol.

What’s your experience with Medicare drug coverage? Have you tried Leqvio or another cholesterol‑lowering therapy? Share your story in the comments below—you might just help someone else make a life‑changing decision.