Does Medicare cover Januvia in North Carolina?

What Januvia is used for

Januvia is a DPP-4 inhibitor tablet. Its FDA label covers improving blood sugar control in adults with type 2 diabetes, along with diet and exercise. It isn't for type 1 diabetes.

This page explains Medicare coverage only. Questions about whether Januvia is right for you belong with your prescriber.

Which part of Medicare covers Januvia

Januvia is a once-daily pill, so it's a Part D drug. Your blood sugar testing supplies are different: meters, test strips and continuous glucose monitors are generally covered by Part B as durable medical equipment, not by your Part D plan. See Medicare Part B.

Is Januvia on Medicare's negotiated-price list?

CMS selected Januvia in the first round of the Medicare Drug Price Negotiation Program. Its negotiated price (the "maximum fair price") took effect January 1, 2026, and Januvia is still on CMS's selected drug list for 2027. A negotiated price is what Medicare drug plans and pharmacies pay; it isn't your copay. What you pay still depends on your plan's cost sharing.

Januvia or Janumet: check the one you take

Januvia is sitagliptin alone. Janumet and Janumet XR combine sitagliptin with metformin in one pill, and CMS selected them separately, in the second round, with a negotiated price effective January 1, 2027. A formulary lists each product separately and can treat them differently, so search for the exact product and strength. If your prescriber is considering switching between them, check both on your plan's formulary first.

What you pay for Januvia in 2027: the out-of-pocket cap

Your cost for Januvia depends on your plan: its deductible, the tier it puts the drug on, and whether you use a preferred pharmacy. This site doesn't list plan costs; your plan's formulary and Evidence of Coverage do. What Medicare sets for everyone with Part D is the limit:

• 2027 out-of-pocket cap: $2,400 (it was $2,100 in 2026). Once what you pay for covered Part D drugs (deductible, copays and coinsurance) reaches the cap, you pay nothing more for covered Part D drugs for the rest of 2027.
• The maximum Part D deductible for 2027 is $700. No plan can set a higher deductible, and some have none.
• Only covered drugs count. If your plan doesn't cover Januvia and you pay cash, or you use a discount card instead of your plan, that spending doesn't count toward the cap.

Spreading the cost: the Medicare Prescription Payment Plan

Every Part D plan and Medicare Advantage plan with drug coverage offers the Medicare Prescription Payment Plan. Instead of paying the pharmacy, you get a monthly bill from your plan that spreads your costs across the calendar year. Medicare.gov says it costs nothing to participate, but it doesn't lower your drug costs; it only changes when you pay. It helps most when costs are high early in the year. To join, call your plan or use its website. More in What is the Medicare Prescription Payment Plan?

Extra Help with Januvia

Extra Help (the Low-Income Subsidy) is a federal program that lowers Part D premiums, deductibles and copays. For 2027, CMS caps Extra Help copays for covered drugs at $5.80 for a generic and $14.40 for a brand-name drug, and some people with full Medicaid pay less. You get Extra Help automatically if you have full NC Medicaid, MQB (North Carolina's name for the Medicare Savings Programs) or SSI; otherwise apply through Social Security at 1-800-772-1213 (TTY 1-800-325-0778) or ssa.gov/extrahelp. See Extra Help in North Carolina.

Getting Januvia covered in North Carolina

North Carolina is its own Part D region (PDP Region 08), so each standalone Part D plan sold here is offered in all 100 counties. For 2027, CMS lists 11 standalone Part D plans from 6 companies in North Carolina. Medicare Advantage choices depend on your county, from 11 plans in Carteret County to 57 in Guilford County, and most include drug coverage. Each plan has its own formulary, so one plan's coverage of Januvia tells you nothing about another's. Your county's numbers are on North Carolina counties.

• Full NC Medicaid and Medicare: your prescriptions are paid by your Medicare drug coverage, not by NC Medicaid, and Extra Help is automatic. People with both are in NC Medicaid Direct. See NC Medicaid and Medicare.
• State Health Plan retirees: the Plan's Base Plan and Enhanced Plan are group Medicare Advantage plans that include group drug coverage. Joining an outside Part D or Medicare Advantage plan removes you from the group plan and moves you to the 70/30 Plan, so check with the Plan first. See State Health Plan retirees and Medicare.
• Hurricanes and floods: CMS expects Part D plans to cover replacements for prescriptions lost or destroyed in a disaster, and plans may relax "refill too soon" limits. Call your plan before a storm if you're running low. See hurricanes, floods and Medicare.
• If your Medicare Advantage plan ends in 2027: you have a special enrollment period through February 28, 2027; choose new drug coverage by December 31, 2026, to avoid a gap. See plans ending in 2027.

North Carolina has no state pharmaceutical assistance program for seniors in general; see Does North Carolina have a prescription assistance program for seniors?

How to check whether a plan covers Januvia

1. Write down the exact drug. Name, strength and how often you take it. A plan can cover one form or strength of Januvia and not another.
2. Look it up in each plan's formulary. Enter your drugs and ZIP code on PlanMatch or Medicare.gov's Plan Finder to see which plans list Januvia and any rules.
3. Read the rules next to the drug. Prior authorization, step therapy or quantity limits mean your prescriber may need to send the plan information before it pays.
4. Check your 2027 notice. Your plan's Annual Notice of Change says whether Januvia stays on the formulary next year. Open Enrollment runs October 15 to December 7, 2026, for coverage starting January 1, 2027.
5. Get help if you want it. You can request a call from a licensed insurance agent, who can compare plans from the companies they work with, or call 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048) for information on all of your options.

If your plan doesn't cover Januvia, you or your prescriber can ask for a coverage determination or a formulary exception. Once the plan has your prescriber's supporting statement, it generally must decide within 72 hours, or 24 hours if your prescriber says waiting could seriously harm your health. New members can usually get a one-time transition supply of a drug they were already taking while they ask for an exception or switch. See Medicare appeals in North Carolina.

Sources

• National Library of Medicine — DailyMed: Januvia prescribing information (FDA label)
• Medicare.gov — Drug coverage (Part D)
• CMS — Selected drugs and negotiated prices (including drugs with deselection determinations)
• eCFR — 42 CFR 423.120 (formularies and transition fills)
• CMS — CY 2027 Rate Announcement (2027 Part D out-of-pocket threshold and Extra Help copays)
• Medicare.gov — Medicare Prescription Payment Plan
• Social Security — Extra Help with Medicare prescription drug plan costs
• CMS — Medicare Advantage and Part D Landscape files, 2027 (PDP Region 08: North Carolina)
• CMS — Replacing Durable Medical Equipment and Prescription Drugs after a Disaster
• NC Medicaid — How to apply

Frequently asked questions

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