Does Medicare Cover Bijuva? What Part D Actually Pays in 2026

Last verified: August 2026 · By The HRT Index Editorial Team · Editorial research — not reviewed by a clinician · Educational only, not medical advice

Does Medicare cover Bijuva? Sometimes. Original Medicare alone does not cover a Bijuva prescription filled through the routine pharmacy benefit. Coverage may come through Part D or a Medicare Advantage drug plan. In our five-formulary 2026 check, three listed Bijuva and two did not; your exact plan and any approved exception control.

That sounds like a non-answer. It isn't. It's the actual shape of the problem, and once you see it, the whole thing gets solvable — because four questions reveal the core coverage terms and the kind of bill you could face. You can check all four before you spend a dollar.

There's also a second thing nobody tells you. The drugmaker runs a Medicare-specific coupon program that most pages barely explain. It can reduce what you pay at the pharmacy. It can also take your Bijuva spending outside Part D for the rest of the calendar year, so none of those dollars count toward your $2,100 Part D out-of-pocket limit. We read the terms line by line, and we'll show you exactly what you'd be agreeing to.

Is this page for you?

This page is for you if: you're on Medicare, you've been prescribed Bijuva or you're about to be, and you want to know whether your drug plan will pay — or you already got a rejection at the pharmacy and don't know what happened.

This page is not for you if: you're trying to decide whether systemic hormone therapy is medically right for you. Coverage research can't answer that. That's a conversation with a clinician who knows your history.

The key constraint: there is no national Bijuva copay. Your exact plan, tier, pharmacy, deductible, coverage stage, Extra Help status, and any approved exception set the number.

Quick answers, up front

Question	Bottom line
Does Original Medicare alone pay for Bijuva at the pharmacy?	No — Original Medicare does not provide the routine retail prescription benefit used for a Bijuva prescription
Can Medicare Part D cover Bijuva?	Yes. Some plans list it; some do not
Can Medicare Advantage cover Bijuva?	Yes, if the plan includes prescription-drug coverage and Bijuva is listed or approved by exception
Is there one Medicare price?	No. It depends on the plan, tier, pharmacy, deductible, coverage stage, and Extra Help
Does the regular Bijuva savings card work with Medicare?	No. The commercial card is not valid for Medicare. A separate Medicare Part D program exists
What if Bijuva is not on my plan's formulary?	Ask for a coverage determination and formulary exception; a prescriber's supporting statement is required for an exception
How fast must the plan decide?	Generally 72 hours for a standard benefit request or 24 hours for an approved expedited request; an exception clock starts when the plan receives the prescriber's supporting statement
What should I do first?	Check the four plan questions below, then ask the pharmacy to run a live claim

The HRT Index is the independent decision resource for online menopause and HRT care — comparing telehealth providers on clinical legitimacy, care quality, medication fit, price transparency, and access, with every claim verified and dated, so women can choose the path that fits their situation before their first consult.

What did we actually verify?

We don't want you taking our word for anything. Here's what we opened and checked for this page.

What we checked	Primary source	What was verified
Bijuva's current prescribing information	FDA, NDA 210132, supplement s013	Indication, strengths, dosing language, current NDCs, ingredients, geriatric-use language, contraindications, warnings, and the February 2026 boxed-warning removal
2026 Part D costs	Medicare.gov	$615 maximum deductible, standard 25% cost sharing after the deductible, and the $2,100 covered-drug out-of-pocket limit
2026 Extra Help amounts	Medicare.gov	$0 premium and deductible, up to $5.10 for generic drugs and $12.65 for brand-name drugs at participating pharmacies
Coverage determinations and appeals	CMS and Medicare.gov	Request types, prescriber-statement requirement, 72-hour and 24-hour initial clocks, 65-day appeal filing window, and redetermination timeframes
Five public 2026 Medicare formularies	The five plan documents linked in our table below	Exact Bijuva listing status, tier, and visible PA, ST, QL, or HRM codes
The standard Bijuva commercial savings card	Current manufacturer card terms	Commercial-insurance requirement, Medicare exclusions, variable cost language, and December 31, 2026 expiration
The Bijuva Medicare Part D Alternative Coupon Program	Mayne Pharma program terms	Eligibility triggers, calendar-year Part D opt-out, no HSA/FSA or insurance reimbursement, no TrOOP credit, and no published guaranteed fill price
Hormone therapy after age 65	The Menopause Society	No universal stopping age, greater caution with later initiation, and the need for individualized reassessment

What we could not verify, and won't pretend we did: we cannot see your live member benefit, deductible balance, pharmacy claim, or exception status. The manufacturer also does not publish one guaranteed price for a fill processed through its Medicare coupon program. Those numbers have to be confirmed through your plan or at the pharmacy.

Which HRT path is right for you?

The right online HRT provider isn't the same for every woman — it depends on your symptoms, your age and whether you have a uterus, your medication route preference (patch, pill, gel, or vaginal estrogen), your risk history, your insurance or cash-pay situation, and your state. Some situations belong with an in-person clinician first. Because a general answer can't resolve those for you, use The HRT Index's Find My HRT Path tool to match your situation to the right provider — and to flag when online care isn't the right starting point — before your first consult.

→ Find My HRT Path

1. Does Medicare cover Bijuva in 2026?

Medicare can cover Bijuva through a stand-alone Part D plan or a Medicare Advantage plan with drug coverage. Original Medicare alone does not provide the routine retail prescription benefit used for a Bijuva prescription filled at a pharmacy. Your exact plan's formulary, tier, restrictions, pharmacy network, and any approved exception control the answer.

Here's the part that trips people up. “I have Medicare” and “I have Medicare prescription-drug coverage” are two different sentences.

Part A is hospital coverage. It is not the ordinary route for a Bijuva prescription you fill at a retail pharmacy and take at home.

Part B is outpatient medical coverage. It covers a limited set of drugs, often drugs a clinician administers or drugs used with certain durable medical equipment. It is not the routine pharmacy benefit for Bijuva.

Part D is the prescription-drug benefit. You can get it through a stand-alone drug plan or through a Medicare Advantage plan that includes drug coverage. Each plan has its own list of covered drugs, called a formulary.

So the real question is not simply “does Medicare cover Bijuva?” It is:

“Is Bijuva on my exact 2026 formulary, what tier is it on, what rules apply, and what will my plan charge at my pharmacy?”

Four questions settle most of it:

1. Is Bijuva listed?
2. What tier is it on?
3. Does that tier charge a flat copay or a percentage of the drug's cost?
4. Does the listing show prior authorization, step therapy, a quantity limit, or another flag?

Most people check only the first question. The third is the one that often predicts the bill. A Tier 3 drug with a $60 copay and a Tier 3 drug with 35% coinsurance can produce very different costs.

Check the correct strength and package

The current FDA label lists two Bijuva strengths in 30-capsule blister packs:

Bijuva strength	Current FDA-listed NDC
0.5 mg estradiol / 100 mg progesterone	68308-751-30
1 mg estradiol / 100 mg progesterone	68308-750-30

An NDC is the product code the pharmacy submits for the exact drug, strength, and package. If a claim rejects, ask which strength and NDC were billed. Do not rely on an old coupon page or old drug database for the code; use the current FDA prescribing information.

Start here: open Medicare Plan Finder, enter every medication you take, select your exact plan or compare plans, and confirm Bijuva with the plan before filling. → Check your 2026 plan on Medicare.gov

2. What did our five-formulary Bijuva Medicare check find?

Bijuva appeared in three of five public 2026 Medicare formularies we checked. Two placed it on Tier 3 and one on Tier 4; two had no exact Bijuva listing. Among the three that listed it, none showed PA, ST, or QL beside Bijuva, while one showed an HRM flag. This is an illustration, not a national coverage rate.

Let's do the honest part first.

We cannot tell you what you'll pay from Medicare status alone. Neither can anyone else.

No public page can determine your exact Bijuva copay from the fact that you have Medicare. Not us. Not a drug-discount site. Not a generic insurer page. A live member portal, a plan representative, or a pharmacy claim can tell you because those sources can see the plan, deductible, pharmacy, coverage stage, and member-specific benefit.

We're not going to add another confident guess to the pile.

Here's the pivot, and it's the whole reason this page exists. The question “what will I pay?” is not reliably answerable from Medicare status alone. The question “am I covered, on what terms, and what should I do next?” is knowable — by you, before you leave the house.

The HRT Index 2026 Bijuva Medicare Formulary Check

Checked August 3, 2026.

Public 2026 formulary	Plan type	Bijuva finding	Visible PA, ST, QL, or HRM	What it means
State of Delaware SilverScript Employer PDP	Employer-sponsored Part D	Both strengths listed, Tier 3	No PA, ST, QL, or HRM shown beside Bijuva	The document defines Tier 3 as Non-Preferred Brand. Employer additional coverage may change how some drugs are processed
UnitedHealthcare Group Medicare Advantage Drug List	Group Medicare Advantage with drug coverage	Bijuva listed, Tier 3	HRM; no PA, ST, or QL shown beside Bijuva	In this document, Tier 3 is non-preferred. HRM is a high-risk-medication flag for older adults, not a denial and not prior authorization
HealthSpring Premier Access five-tier formulary	Named HealthSpring PDP and Medicare Advantage plan families	Both strengths listed, Tier 4	No PA, ST, QL, or HRM shown beside Bijuva	The document defines Tier 4 as Non-Preferred Drugs. The drug rows were dated July 17, 2026
Kaiser Permanente 2026 Comprehensive Formulary	Multi-region Medicare Advantage and D-SNP formulary	No exact Bijuva listing found	Not applicable	“Not found” is not the same as a final claim denial. The member should confirm the live formulary and can request an exception
CDPHP 2026 Medicare Advantage Formulary	Medicare Advantage drug plans	No exact Bijuva listing found	Not applicable	The July 2, 2026 public formulary contains an exception route for drugs that are not listed

What this sample proves

• Bijuva is not universally excluded from Medicare formularies.
• Bijuva is not universally listed either.
• Tier placement varies.
• A plan can display an HRM flag without displaying PA, ST, or QL.
• Employer and group plans can include benefit rules that do not apply to an individual-market plan.

What this sample does not prove

It does not establish a national coverage percentage. Five public documents are an evidence sample, not a representative survey of thousands of Part D and Medicare Advantage plans. A public PDF can also lag behind a live member benefit.

The original restriction finding

Across the three formularies that listed Bijuva in this check:

• 0 showed prior authorization beside Bijuva.
• 0 showed step therapy beside Bijuva.
• 0 showed a quantity limit beside Bijuva.
• 1 showed an HRM flag.

That does not mean your plan has no restriction. It means a blanket claim that “Bijuva always needs prior authorization on Medicare” is not supported by these plan documents.

Take the four questions with you. The worksheet below carries the current NDCs, plan questions, pharmacy script, rejection checklist, coupon trade-off, and exception fields on one page. → Open the Bijuva Medicare Coverage Worksheet

3. How do you check your own Medicare plan in about ten minutes?

Check the current formulary for your exact plan — not the insurance company's general drug page. Search both Bijuva strengths, record the tier and every code, then ask the plan whether the tier uses a copay or coinsurance at your pharmacy. A pharmacy rejection is useful evidence, but a formal coverage determination is the plan's written decision.

Step 1 — Know exactly which plan you have

Not “I have Humana” or “I have UnitedHealthcare.” You need:

• The full plan name.
• The 2026 plan year.
• Whether it is a stand-alone Part D plan, an MA-PD plan, or an employer/retiree plan.
• Your ZIP code or service area.
• The contract and plan ID if they appear on your card or plan materials.

One insurer can run many formularies in the same state.

Step 2 — Look up both strengths

Search for:

• Bijuva 0.5 mg/100 mg — NDC 68308-751-30.
• Bijuva 1 mg/100 mg — NDC 68308-750-30.

A plan may list both, one, or neither. The prescription strength still comes from your clinician; this step is only about checking benefit records accurately.

Step 3 — Write down everything, not just yes or no

Capture:

• Listed or not found.
• Tier number and the plan's name for that tier.
• PA — prior authorization.
• ST — step therapy.
• QL — quantity limit.
• HRM — high-risk medication.
• Preferred pharmacy status.
• Mail-order status.
• Any footnote or special symbol.

Do not assume restriction codes are standardized across plans. One formulary may use HRM; another may not use that abbreviation at all. Read the code key in the same document.

Step 4 — Ask the pharmacy to run the claim

A live claim can reveal what a public PDF cannot:

• Whether your deductible is being applied.
• Whether the pharmacy is preferred, standard, or out of network.
• Whether a coverage rule is blocking the claim.
• Whether it is too soon to refill.
• Whether the wrong strength or package was submitted.
• Your member-specific cost at that moment.

You do not have to accept or buy the prescription simply because the claim was run. Ask the pharmacy what the rejection message says and write it down.

Step 5 — If the answer is unclear, request it in writing

A pharmacist saying “not covered” may be describing the result of one claim. A coverage determination is the plan's formal benefit decision. You or your prescriber can request one by calling the plan, writing to it, or using the CMS model coverage-determination form.

The call script — copy this

“I'm checking Bijuva under my 2026 drug benefit. Please check both strengths: 0.5 mg/100 mg and 1 mg/100 mg. Is either strength on my current formulary? What tier is it on, and does that tier use a flat copay or coinsurance? Does it have prior authorization, step therapy, a quantity limit, or an HRM flag? What would I pay at a preferred network pharmacy before and after my deductible? If it is not covered, how do I request a coverage determination and formulary exception?”

Write down the date, the representative's name or ID, and the call reference number.

Bijuva Medicare Coverage Worksheet

Use this at the plan portal, on the phone, or at the pharmacy.

Do not enter your Medicare number, member ID, Social Security number, or date of birth into a worksheet or tool on The HRT Index. Keep identifying information only in your own private plan records.

Your plan

• Full plan name: ______________________________
• Plan type: PDP / MA-PD / employer-retiree / other
• Plan year: 2026
• ZIP or service area: __________________________
• Preferred pharmacy confirmed? Yes / No

Bijuva search

Strength	NDC	Listed?	Tier	Copay or coinsurance?	PA	ST	QL	HRM
0.5 mg/100 mg	68308-751-30
1 mg/100 mg	68308-750-30

Pharmacy result

• Pharmacy name: ______________________________
• Preferred / standard / out of network: __________________
• Price quoted today: $________________________
• Deductible remaining, if known: $________________
• Rejection message or code: ______________________________

If the claim rejected

Check every one before assuming the drug is permanently denied:

• [ ] Bijuva is not on the formulary.
• [ ] Prior authorization is required.
• [ ] Step therapy applies.
• [ ] The quantity exceeds the plan limit.
• [ ] The pharmacy is not in network or not preferred.
• [ ] It is too soon to refill.
• [ ] The wrong strength or NDC was submitted.
• [ ] The deductible is being applied.

If you need an exception

• Date coverage determination requested: __________________
• Prescriber supporting statement sent: Yes / No / Date __________
• Standard or expedited: __________________
• Plan decision deadline: __________________
• Decision and reference number: __________________________
• Appeal deadline if denied: ______________________________

If you are considering Mayne's Medicare coupon

• Does the plan exclude Bijuva? Yes / No
• If covered, is your cost more than $50 for 30 capsules, $100 for 60, or $150 for 90? Yes / No
• Are you already close to the $2,100 Part D out-of-pocket limit? Yes / No / Unknown
• Have you read and accepted the calendar-year opt-out, no-TrOOP, no-HSA/FSA, and no-other-card terms? Yes / No

4. How much does Bijuva cost with Medicare Part D?

There is no single Medicare price for Bijuva. In 2026, a Part D plan can have a deductible up to $615. Under the standard benefit, you generally pay 25% after the deductible until covered Part D out-of-pocket spending reaches $2,100, then covered Part D drugs cost $0 for the rest of the calendar year. Your plan may use copays or an enhanced design.

The 2026 rules, from Medicare directly

Part D cost element	2026 rule
Maximum plan deductible	$615; some plans charge less or $0
Standard cost sharing after the deductible	Generally 25% for covered generic and brand-name drugs until the out-of-pocket limit
Annual covered-drug out-of-pocket limit	$2,100
After the limit	$0 out of pocket for covered Part D drugs for the rest of the calendar year
Premium	Separate from the $2,100 limit and set by the plan

Source: Medicare.gov's 2026 Part D cost page.

Two things about that $2,100 limit matter later on this page.

First, it applies to out-of-pocket spending that counts under the Part D benefit for covered Part D drugs. A Bijuva purchase processed entirely outside your plan through cash, a discount card, or Mayne's Medicare coupon does not move you toward the limit.

Second, certain payments made on your behalf — including eligible Extra Help payments — can count.

The number that actually predicts your bill

Everyone asks, “What tier is it?” That's the right first question and the wrong last one.

A plan can charge a fixed copay or a percentage called coinsurance. A $60 copay stays $60 for that fill under the plan's current rules. A 35% coinsurance amount moves with the plan's negotiated price and the coverage stage.

So the question is not just “what tier?” It is “does that tier use a copay or coinsurance at my pharmacy, and does my deductible apply?”

The seven inputs that determine your Bijuva cost

Input	Why it changes the number
Formulary status	A non-formulary drug generally needs an approved exception to be covered under Part D
Tier	Higher or non-preferred tiers often cost more
Copay versus coinsurance	One is fixed; the other is a percentage
Deductible	The first fill can be much higher before the deductible is met
Pharmacy	Preferred and standard network pharmacies can charge different member amounts
Coverage stage	Your cost changes when you move through the Part D stages
Extra Help	Eligible beneficiaries receive lower Part D premiums, deductibles, and drug cost sharing

If your plan does not cover Bijuva

Do not anchor on a national “retail price.” Cash and discount-card prices can change by pharmacy, ZIP code, day, and card. Ask at least two pharmacies for the price you could actually pay that day, then compare that number with:

1. The cost if a formulary exception is approved.
2. The manufacturer's Medicare-coupon terms.
3. The effect of taking the purchase outside Part D.

The cheapest-looking fill can be the more expensive annual decision if it stops meaningful spending from counting toward your $2,100 limit.

What women actually say about the cost

These are short, individual cost experiences — not evidence of typical coverage, safety, or effectiveness:

“quite PRICEY and my insurance won't cover it” — r/Menopause

“with insurance it's still $200/month. Is it worth that?” — r/Menopause

That second question is the question underneath this whole page. We cannot answer whether Bijuva is worth it for you. We can make sure you're answering with your real plan number instead of a guessed one.

Can the Medicare Prescription Payment Plan help?

The Medicare Prescription Payment Plan can spread your out-of-pocket costs for drugs covered by your plan across the calendar year. It costs nothing to join, but it does not lower the total amount or create coverage for a drug your plan excludes.

A Bijuva purchase made outside Part D through Mayne's alternative coupon cannot be placed into the Medicare Prescription Payment Plan because it is not being processed as a covered Part D purchase.

5. What tier is Bijuva on Medicare formularies?

There is no national Bijuva tier. In our five-formulary 2026 check, Bijuva appeared on Tier 3 in two documents and Tier 4 in one, while two had no exact listing. Even the same tier number can mean “preferred brand” in one plan and “non-preferred” in another, so the tier label and cost-sharing rule matter together.

The sample shows why a tier number by itself is incomplete:

Formulary	Bijuva tier	What that plan calls the tier
Delaware SilverScript Employer PDP	Tier 3	Non-Preferred Brand
UnitedHealthcare Group Medicare Advantage	Tier 3	Non-preferred
HealthSpring Premier Access	Tier 4	Non-Preferred Drugs

Other plans may define their tiers differently. Always read the tier key in your own formulary and the cost-sharing table in your Evidence of Coverage.

What an HRM flag means — and what it does not

If you see HRM beside Bijuva, it means the plan has marked it as a high-risk medication for older adults in that formulary system.

Here is what it is: a flag that should prompt an age- and risk-specific conversation with the prescriber.

Here is what it is not: an automatic denial, a prior-authorization code, or proof that the medication is inappropriate for every woman over 65. Those are different questions.

Can you ask for a lower tier?

You or your prescriber may ask for a tiering exception when a covered drug has high cost sharing. The plan's own rules control whether the request is available and what lower tier can be used. Drugs on a specialty tier generally are not eligible for a tiering exception.

A tiering exception is different from a formulary exception. If Bijuva is not listed at all, ask for a formulary exception. If it is listed but expensive, ask whether a tiering exception is available.

6. Does Bijuva require prior authorization, step therapy, or a quantity limit?

There is no universal Medicare rule for Bijuva. In the three public 2026 formularies in our sample that listed it, none displayed PA, ST, or QL beside Bijuva; one displayed HRM. Your plan can apply different rules, and a live claim or current member formulary controls. “On the formulary” and “ready to fill without another step” are not always the same.

What each rule means

Prior authorization (PA) — the plan requires information showing that its coverage criteria are met before it will cover the drug.

Step therapy (ST) — the plan requires a covered alternative to be tried first unless the plan approves an exception to that rule.

Quantity limit (QL) — the plan limits the amount it covers during a stated period.

High-risk medication (HRM) — an older-adult risk flag used by some plans. It is not the same as PA, ST, or QL.

Non-extended day supply (NDS) — a plan-specific code used in some formularies to limit extended supplies. Not every plan uses this code.

If your claim was rejected, run this list first

Before you panic, ask the pharmacy which one applies:

1. Bijuva is not on the formulary.
2. Prior authorization is required and has not been completed.
3. Step therapy applies.
4. The quantity exceeds the plan limit.
5. The pharmacy is not in network or is not preferred.
6. It is too soon to refill.
7. The wrong strength or NDC was submitted.
8. The deductible is being applied.

Numbers 5 through 8 may be fixable without a formulary appeal. Get the exact rejection message before you start the wrong process.

Don't try to hold all of that in your head at the pharmacy counter. → Use the Bijuva rejection checklist

7. Can you use a Bijuva coupon with Medicare?

Not the standard commercial card. Mayne's regular Bijuva copay card is not valid for Medicare, Medicare Advantage, Part D, Medigap, Medicaid, or the other government programs listed in its terms. Mayne runs a separate Bijuva Medicare Part D Alternative Coupon Program with different eligibility rules and a calendar-year Part D opt-out for Bijuva.

This is the most important distinction on the page. Two programs. Same manufacturer. Opposite Medicare eligibility.

	Bijuva commercial copay card	Bijuva Medicare Part D Alternative Coupon Program
Who it is for	Eligible commercially insured patients whose plan covers a valid Bijuva prescription	Eligible people with Part D or Medicare Advantage drug coverage
Medicare eligibility	Not valid for Medicare, Medicare Advantage, Part D, Medigap, or the other government programs named in the terms	Part D or Medicare Advantage drug coverage is required
Cash payers	Not eligible	Uninsured patients are not eligible
Trigger	Commercial coverage and a covered Bijuva prescription	Plan does not cover Bijuva, or plan out-of-pocket cost exceeds $50 for 30 capsules, $100 for 60, or $150 for 90
Guaranteed price published?	No. Cost may vary and maximum reimbursement limits apply	No. Maximum limits apply; the patient pays costs after reimbursement limits are reached
HSA/FSA reimbursement	Terms prohibit reimbursement for the value received from the card	Terms prohibit submitting the Bijuva out-of-pocket cost to an HSA, FSA, insurance plan, or other reimbursement account
Other coverage exclusions	Federal and state program exclusions include Medicare, Medicaid, TRICARE, VHA, DOD, IHS, and state pharmacy-assistance programs	Commercial/private insurance, Medicaid, TRICARE, DOD, VHA, IHS, SCHIP, and other state or federal health-program coverage make a patient ineligible
Part D credit	Not applicable because Medicare beneficiaries are excluded	No TrOOP credit for Bijuva purchased through the program
Current duration	Commercial card expires December 31, 2026	Valid from approved enrollment through the end of that calendar year

Sources: commercial card terms and Medicare Part D Alternative Coupon Program terms.

What about the “$35 Bijuva” claim?

The current manufacturer materials do not promise one fixed $35 Medicare or commercial-card price. The commercial card says out-of-pocket costs may vary and maximum limits apply. The Medicare program says patients are responsible for additional costs after reimbursement limits are reached.

The real amount is established when the pharmacy processes the current offer for an eligible patient. Do not publish or rely on a fixed manufacturer price unless it appears in the current manufacturer terms or is confirmed during claim processing.

Use the current card, not copied processing numbers

Manufacturers can amend or replace programs. Download the current card or coupon directly from the manufacturer and give that version to the pharmacist rather than typing card numbers copied from an old page.

Read the Medicare program terms before enrolling. The next section translates the clauses that change the decision. → Read Mayne's current Medicare Part D program terms

8. What are you agreeing to before you use Mayne's Medicare coupon?

Mayne's Medicare Part D Alternative Coupon Program is a coupon outside your Part D benefit — not Medicare coverage and not insurance. To use it, you agree to stop purchasing Bijuva through Part D for the rest of the calendar year. Your Bijuva spending then earns no TrOOP credit and cannot be submitted to insurance, an HSA, or an FSA.

We read every clause on the enrollment page. Here is the ledger in plain language.

By enrolling, you agree that:

1. You are opting out of using your prescription insurance for Bijuva for the remainder of the calendar year.
2. If you purchase Bijuva again that year, you will not purchase it through Part D even if your benefits change.
3. You will not seek true out-of-pocket credit under a government program for the Bijuva cost. Those dollars do not move you toward the $2,100 Part D out-of-pocket limit.
4. You will not submit the Bijuva cost to an insurance plan, health savings account, flexible spending account, or another healthcare reimbursement account.
5. You will notify your prescription plan by sending Mayne's opt-out letter.
6. You will not combine the program with another coupon, free trial, discount card, prescription savings card, or other offer.
7. De-identified redemption data may be collected, analyzed, and shared with Mayne; the program also states that Mayne and InfinityRx may store personal and medical information for program administration.

The trade-off, in one paragraph

Because the Bijuva purchase is outside Part D, it does not help you reach the $2,100 limit. If you were unlikely to reach that limit anyway, the lost credit may have little practical effect. If you are already accumulating substantial covered-drug spending, moving Bijuva outside the benefit can delay the point when covered Part D drugs become $0 for the rest of the year.

That is the calculation:

Pharmacy savings today versus the value of Part D credit you give up for the rest of the year.

The two-branch decision

The program may be worth comparing when Bijuva is not covered, an exception has failed or is not yet available, and you are not on track to reach the $2,100 covered-drug limit.

Use extra caution before opting out when your plan covers Bijuva, you have Extra Help, you are close to the $2,100 limit, or you take other expensive covered drugs. In those situations, Part D credit may be worth more than it first appears.

It cannot use the Medicare Prescription Payment Plan

The Medicare Prescription Payment Plan spreads out-of-pocket costs for drugs covered by your plan. A Bijuva purchase made with Mayne's alternative coupon is outside the plan benefit, so it cannot be included.

Where the program is available

The manufacturer states that eligible patients may use the program in the United States, including Puerto Rico, Guam, and the U.S. Virgin Islands, at participating U.S. retail pharmacies. Product must originate in the United States.

This is editorial analysis of the published manufacturer terms and Medicare rules, not financial advice. Compare your own plan spending before signing the opt-out.

9. Should you check Extra Help before using any coupon?

Yes. In 2026, Extra Help charges up to $12.65 for a covered brand-name drug at a participating pharmacy, with a $0 Part D premium and deductible. Mayne's cost-based coupon trigger starts only when the insured amount exceeds $50 for 30 capsules. If your plan covers Bijuva and Extra Help applies, $12.65 does not meet that cost trigger.

This is the piece of arithmetic that resolves the page for many readers.

What Extra Help pays in 2026

Part D cost with Extra Help	2026 amount
Plan premium	$0
Plan deductible	$0
Generic drug at a participating pharmacy	Up to $5.10
Brand-name drug at a participating pharmacy	Up to $12.65
Covered drugs after the Part D $2,100 limit is reached	$0

Source: Medicare.gov Extra Help amounts for 2026.

Now put the numbers beside each other:

• Extra Help: up to $12.65 for a covered brand-name drug.
• Mayne's cost trigger: insured out-of-pocket cost must exceed $50 for 30 capsules.

$12.65 does not exceed $50. If your plan covers Bijuva and your Extra Help pricing is being applied correctly, the cost-based trigger cannot be met.

The exception you must keep beside that arithmetic

The manufacturer program has two triggers. If your plan does not cover Bijuva at all, the noncoverage trigger can still apply. Extra Help reduces the price of covered Part D drugs; it does not automatically turn a non-formulary drug into a covered drug. But Mayne excludes patients who also have Medicaid or another state or federal health-program coverage named in its terms, so confirm every eligibility condition before enrolling.

That makes the order of operations clear:

1. Confirm whether Bijuva is listed.
2. If it is not, request a formulary exception.
3. Confirm that Extra Help is attached to your plan record.
4. Compare the exception result with the manufacturer program only after those checks.

Who can qualify for Extra Help?

For 2026, Medicare lists general income and resource limits of:

Situation	Income limit	Resource limit
Individual	$23,940	$18,090
Married couple	$32,460	$36,100

Different limits apply in Alaska and Hawaii, and some people qualify automatically through Medicaid, a Medicare Savings Program, or Supplemental Security Income.

Extra Help is not available in Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, or American Samoa; local assistance programs differ in those areas.

This is worth checking even if you assume you will not qualify. → Apply for Extra Help through Social Security

10. Your plan said no. What exactly should you do?

A rejection is the start of a process, not the end. Ask for the pharmacy's rejection reason, then request a formal coverage determination. If Bijuva is not on the formulary, ask for a formulary exception with your prescriber's medical statement. Standard benefit decisions are generally due in 72 hours and expedited decisions in 24 hours; exception clocks start when the plan receives the supporting statement.

First, get the pharmacy notice

When a Part D pharmacy will not fill a prescription as written, ask for the “Medicare Drug Coverage and Your Rights” notice. It explains that you can contact the plan for a coverage determination. CMS publishes the current Part D plan notices and documents.

The five requests — and which one you want

Request	Use it when	What you are asking for
Coverage determination	You need a formal benefit answer	Decide whether Bijuva is covered, whether a rule is met, and what you owe
Formulary exception	Bijuva is not on the plan's list	Cover Bijuva despite its non-formulary status
Tiering exception	Bijuva is covered but the tier is expensive	Apply lower cost sharing if the plan's rules allow it
Utilization-management exception	PA, ST, or QL is blocking coverage	Waive or modify the restriction for your situation
Redetermination	The initial coverage determination was denied	Reconsider the plan's denial at appeal level 1

The initial decision clocks

For a request for a drug you have not yet received:

• Standard benefit determination: generally 72 hours.
• Expedited benefit determination: generally 24 hours when waiting could seriously jeopardize life, health, or the ability to regain maximum function.
• Exception request: the 72-hour or 24-hour clock starts when the plan receives the prescriber's supporting statement.

What the prescriber needs to explain

For an exception, the prescriber must give the medical reason it should be approved. Plans generally look for an explanation that:

• The covered alternatives would not be as effective for the patient.
• The alternatives would cause adverse effects.
• Applying the plan's restriction would be medically inappropriate for the patient.

Do not invent a reason for the clinician to sign. Give the clinician an accurate medication history, previous responses, adverse effects, contraindications, and the plan's stated criteria so the supporting statement is based on the chart.

If the first decision is denied

A level 1 Part D appeal is called a redetermination.

• You, your representative, or your prescriber generally have 65 days from the date on the initial denial notice to request it.
• A standard benefits appeal is generally decided in 7 days.
• A fast appeal is generally decided in 72 hours when the expedited standard is met.
• If the redetermination is denied, the notice explains the next independent-review level and deadline.

Follow the dates on the actual denial notice; do not wait for a general article to tell you that a filing window is closing.

If you are new to the plan, ask about a transition fill

During the first 90 days after you join a Part D plan, the plan generally must provide at least a 30-day retail transition supply when its transition rules apply to a drug you have been taking that is non-formulary or subject to prior authorization or step therapy, unless the prescription is written for less. The transition fill is breathing room, not permanent approval. Use it to start the coverage or exception process immediately.

If the plan changes the formulary mid-year

For many changes that affect a drug you are already taking, the plan must either:

• Give written notice at least 30 days before the change becomes effective; or
• At the next refill, provide notice and at least a month's supply under the prior rules.

There are exceptions for certain immediate substitutions and market withdrawals. The plan's notice should explain the change and the exception route.

Print the worksheet before you call. It gives you the request type, the 72-hour and 24-hour clocks, and a place to record the appeal deadline. → Open the Bijuva exception checklist

11. Does employer or retiree drug coverage change the rules?

It can. Some employer, union, or retiree Medicare plans add coverage for drugs outside the standard Part D benefit. When a drug is paid under that additional coverage, the plan document may state that the spending does not count toward Part D out-of-pocket totals and that Part D appeals, exceptions, or Extra Help do not apply to that drug. Ask which benefit is paying.

This one is quiet and expensive.

The State of Delaware SilverScript employer formulary states that the employer may cover some drugs not included in the Medicare Part D benefit. It also states that payments for those drugs do not count toward Part D out-of-pocket costs and that those drugs are not subject to the Part D appeals and exceptions process.

Other employer, union, or trust arrangements may have different supplemental rules. A drug can appear on a combined drug list, be paid for, and still be processed outside the Part D benefit you assumed you were using.

Ask this exact question:

“Is Bijuva covered under my Part D benefit, or under my employer's additional coverage?”

Then ask three follow-ups:

1. Does my Bijuva spending count toward the $2,100 Part D out-of-pocket limit?
2. Does Extra Help apply to this Bijuva claim?
3. Which appeal or exception process applies if the claim is denied?

Do not assume the answer from the plan name. Get it from the plan's benefit record.

12. Should you switch Part D plans over one drug?

Sometimes — but compare the total annual cost of every medication, the premium, deductible, pharmacy network, and coverage rules before switching. A plan that makes Bijuva cheaper can cost more overall. Medicare Open Enrollment runs October 15 through December 7, with changes generally effective January 1; Special Enrollment Periods apply only in qualifying situations.

Switching for one drug is an easy way to save $40 in one place and lose $400 somewhere else.

Compare the full year, not one pharmacy quote

Include:

• Monthly premium.
• Deductible and which tiers it applies to.
• Bijuva's formulary status and tier.
• Copay versus coinsurance.
• PA, ST, QL, and HRM flags.
• Every other prescription you take.
• Preferred-pharmacy status for the pharmacies you actually use.
• Mail-order rules.
• Extra Help treatment.
• Whether any employer supplemental coverage sits outside Part D.

Read the Annual Notice of Change

Your plan sends an Annual Notice of Change each fall describing changes in coverage and costs that take effect in January. Medicare says plans send it in September; the 2026 Medicare handbook says the printed copy is sent by September 30.

Do not recycle it before checking:

• Whether Bijuva remains listed.
• Whether its tier changes.
• Whether a new restriction appears.
• Whether your pharmacy remains preferred.
• Whether the premium or deductible changes.

When can you switch?

• Medicare Open Enrollment: October 15 through December 7; changes generally start January 1.
• Medicare Advantage Open Enrollment: January 1 through March 31 for people already in Medicare Advantage, with a narrower set of options.
• Special Enrollment Period: available only when a qualifying event creates one.

Compare using your complete drug list — not Bijuva alone. → Compare plans on Medicare.gov

13. Is Bijuva the right medication to discuss after age 65?

Coverage and clinical fit are separate questions. Bijuva is FDA-approved for moderate-to-severe vasomotor symptoms due to menopause in a woman with a uterus. Its label says to consider initiation before age 60 or within 10 years of menopause onset and says too few women over 65 were studied to determine whether their response differs. Later-life use needs individualized review.

We want to handle this carefully, because this is where a coverage page can accidentally do harm.

What the current FDA label says

Bijuva is an FDA-approved oral prescription medicine combining estradiol and progesterone. It is indicated for moderate-to-severe vasomotor symptoms due to menopause in a woman with a uterus.

The label says:

• Take one capsule each evening with food.
• Generally start with 0.5 mg estradiol/100 mg progesterone, with dose adjustment based on clinical response.
• Consider initiation in women under 60 or within 10 years of menopause onset.
• Attempt to taper or discontinue at three- to six-month intervals.
• Too few women over 65 were included in Bijuva studies to determine whether their response differs from younger women.

Those are prescribing-label statements, not a decision about any individual woman.

Age 65 is not a stop sign

The Menopause Society states that there is no universal age limit for stopping hormone therapy. Continuing after 65 may be reasonable for selected women with persistent symptoms after careful assessment, counseling, dose and regimen selection, and ongoing reassessment.

Starting hormone therapy after 65 is a different question. The Menopause Society's 2026 discussion of later initiation reinforces the need for individualized risk-benefit assessment and close monitoring, rather than treating continuation and first-time initiation as the same decision.

The 2026 boxed-warning change

In February 2026, the FDA approved removal of Bijuva's boxed warning. That is a labeling change. It does not mean the underlying risks disappeared.

The current label still contains contraindications and warnings involving conditions such as unexplained genital bleeding, breast cancer or a history of breast cancer, estrogen-dependent neoplasia, blood clots, stroke or myocardial infarction, liver disease, and thrombophilic disorders. It also retains warnings about cardiovascular disorders and malignant neoplasms.

Anyone using the boxed-warning removal to tell you Bijuva is now risk-free is misreading the label.

What if you have had a hysterectomy?

The FDA-approved patient labeling says not to use Bijuva after the uterus has been removed. Bijuva contains progesterone to reduce the chance of endometrial cancer in a woman using estrogen who has a uterus.

Do not let a formulary listing decide this. Ask the prescriber whether a combined estradiol-progesterone product fits your anatomy and treatment goal.

Keep the two questions separate

Medicare question	Clinical question
Is Bijuva listed?	Is systemic oral hormone therapy appropriate?
What tier is it?	Is this route, dose, and combination appropriate?
Does the plan require PA, ST, or QL?	Are there contraindications or risk factors?
What will the fill cost?	Is the expected benefit worth the individualized risk?
Can an exception be approved?	Is Bijuva preferable to another clinically appropriate regimen?

Coverage can tell you whether the plan will pay. It cannot tell you whether this is the right treatment. → Find the care path that fits your situation

14. If Bijuva stays out of reach, what FDA-approved options can you ask about?

If Bijuva is not covered, unaffordable, or not clinically appropriate, ask the prescriber and plan about FDA-approved alternatives. Separate estradiol and progesterone products are not Bijuva and should not be assembled without a clinician. An FDA-approved generic of Bijuva 1 mg/100 mg exists on paper but is not currently marketed under the settlement's planned entry date.

Separate estradiol plus separate progesterone

A clinician may consider separate FDA-approved estradiol and progesterone prescriptions. That is a different regimen, not a generic substitution for Bijuva and not a do-it-yourself equivalent.

Formulation details can matter. The current Bijuva label lists lecithin among its inactive ingredients and does not list peanut oil. The current Prometrium label lists peanut oil and contraindicates Prometrium in patients allergic to peanuts.

That does not mean every progesterone capsule contains peanut oil. It means the exact product label matters. If an ingredient is a problem, make sure the allergy and the affected product are documented in the medical record and exception request.

Other FDA-approved combination products

Other oral estrogen-progestogen products exist, including estradiol/norethindrone acetate combinations. Whether one is appropriate depends on the indication, uterine status, route, risk history, dose, and the plan's formulary. “Covered” is not the same as “clinically interchangeable.”

Is there a generic Bijuva?

There is no generic Bijuva you can routinely buy today.

The FDA approved Amneal's ANDA 214293 for estradiol and progesterone capsules, 1 mg/100 mg, on May 16, 2022. The approval letter found it therapeutically equivalent to Bijuva 1 mg/100 mg. A patent settlement announced a licensed U.S. entry date of May 25, 2032, with the possibility of earlier entry under specified circumstances.

So both of these statements are wrong:

• “No generic has ever been approved.”
• “Ask your pharmacy for the generic today.”

The accurate answer is: FDA-approved, not currently marketed for routine purchase, with a planned 2032 entry date subject to the settlement terms.

Sources: FDA ANDA approval letter and patent-settlement announcement.

What about compounded hormones?

Compounded hormone preparations are not FDA-approved, and the FDA does not review them before marketing for safety, effectiveness, or quality. They are not generic Bijuva and are not the same category of product.

We will not present a compounded product as equivalent to Bijuva, as safer or more natural, or as the default answer to an FDA-approved brand-coverage problem. The FDA's compounding guidance says compounded drugs should be used when a patient's medical needs cannot be met by an FDA-approved drug.

If what you need is a clinician who will work through the options

A clinician cannot make a Medicare plan cover Bijuva. A clinician can determine whether Bijuva or another regimen is medically appropriate, document why covered alternatives are unsuitable, and provide the supporting statement an exception requires.

The right route depends on your symptoms, age, uterine status, risk history, treatment preference, insurance, and state — which is exactly what a generic provider link cannot resolve.

→ Use Find My HRT Path to identify the right starting point

15. How did The HRT Index verify this page?

The HRT Index Verification Standard is our documented process: read published prices and program terms, separate FDA-approved from compounded options, verify coverage and availability against current primary sources, and recheck material claims on a fixed schedule. It is not a numeric score, and we do not invent scores for providers or medications.

We evaluate provider and care-path evidence on five pillars, always in this order: clinical legitimacy, care quality, medication fit, price transparency, access.

Who created this page

The HRT Index Editorial Team produced this page. It is editorial research and has not been reviewed by a clinician. We do not attach a doctor's name or credentials that were not part of the work.

How it was made

We checked:

• The current FDA Bijuva label and February 2026 revision.
• 2026 Medicare Part D costs, Extra Help, payment-plan, coverage-determination, appeal, transition-fill, and enrollment rules.
• Five public 2026 Medicare formulary documents, including their tier keys and restriction codes.
• The current commercial Bijuva card and Medicare Part D Alternative Coupon Program terms.
• The Menopause Society's age-65 guidance.
• The FDA generic approval, patent-settlement announcement, Prometrium label, and FDA compounding guidance.

Every plan row in the five-formulary table was checked directly against the linked public document. “No exact Bijuva listing found” means exactly that; it does not claim a live member request or exception would be denied.

Why this page exists

This page exists to help a Medicare beneficiary make the next correct administrative decision before she pays cash, gives up after a pharmacy rejection, changes medication, or signs away Part D credit without understanding the trade-off.

Our limits, stated plainly

• A public formulary PDF is not a live claim under your member record.
• “Not found in the document” is not the same as “your exception will be denied.”
• Employer supplemental coverage can change which rules apply.
• Five formularies are an illustration, not a national survey.
• We reviewed no medical records and ran no claim for you.
• We cannot publish one manufacturer-coupon fill price because the current terms do not guarantee one.

When this page will be rechecked

Element	Recheck cadence	Trigger for an immediate update
Mayne Medicare coupon terms and thresholds	Monthly	Eligibility, opt-out, reimbursement, privacy, or TrOOP term changes
Commercial Bijuva card	Monthly	New card, price language, eligibility change, or December 2026 expiration
Five formulary rows	Quarterly	New formulary PDF, tier change, restriction, or reader correction
FDA Bijuva label	Quarterly monitoring	Label revision, safety communication, NDC, indication, or warning change
Medicare deductible, out-of-pocket limit, and Extra Help amounts	Annually and each fall	CMS publishes the next plan-year figures
Appeals and enrollment rules	Quarterly	CMS or Medicare guidance changes
Find My HRT Path description and timing	Quarterly	Tool flow, privacy handling, or duration changes

The “Last verified” date changes only after the material claims are rechecked.

16. What else should you know about Bijuva and Medicare?

Does Original Medicare cover Bijuva?

Original Medicare alone does not provide the routine retail prescription-drug benefit used for a Bijuva prescription filled at a pharmacy. The relevant coverage route is a stand-alone Part D plan or a Medicare Advantage plan with drug coverage.

Does Medicare Part D cover Bijuva?

Some plans do and some do not. In our five-formulary 2026 check, three listed Bijuva and two had no exact listing. Your current formulary, live benefit, and any approved exception control.

Does Medicare Advantage cover Bijuva?

It can if the Medicare Advantage plan includes prescription-drug coverage and lists Bijuva or approves it by exception. Check the exact plan, not the insurer's general drug page.

What tier is Bijuva on?

There is no national tier. We found Tier 3 in two public formularies and Tier 4 in one. The plan's definition of the tier and whether it uses a copay or coinsurance matter as much as the number.

Does Bijuva require prior authorization?

There is no universal rule. None of the three formularies in our sample that listed Bijuva displayed PA beside it, but another plan may apply PA or another rule. Check the live member formulary and pharmacy claim.

How much will Bijuva cost with Medicare?

There is no single price. In 2026, the plan deductible can be up to $615. Under the standard Part D design, you generally pay 25% after the deductible until covered-drug out-of-pocket spending reaches $2,100. Your plan may use copays or an enhanced design.

Can I appeal if my plan denies Bijuva?

Yes. Request a coverage determination. If Bijuva is not on the formulary, request a formulary exception with the prescriber's supporting statement. If the initial decision is denied, a level 1 appeal is a redetermination, generally requested within 65 days of the denial notice.

How quickly must the plan decide an exception?

A standard benefit request is generally due within 72 hours and an approved expedited request within 24 hours. For an exception, that clock starts when the plan receives the prescriber's supporting statement.

Can I use the regular Bijuva savings card with Medicare?

No. The current commercial card is not valid for Medicare, Medicare Advantage, Part D, Medigap, or the other government programs named in its terms.

Is there a separate Bijuva program for Medicare?

Yes. Mayne's Bijuva Medicare Part D Alternative Coupon Program may apply when Part D or an MA-PD plan does not cover Bijuva or the insured out-of-pocket cost exceeds $50 for 30 capsules, $100 for 60, or $150 for 90. It is a coupon outside Part D, not insurance.

Does spending through that program count toward the $2,100 Part D limit?

No. The terms require the participant not to seek TrOOP credit for Bijuva purchased through the program, so that spending does not move her toward the Part D limit.

Can I return to Part D for Bijuva later in the same year?

The manufacturer terms say the participant will no longer purchase Bijuva through Part D for the remainder of the calendar year, even if benefits change. Read the current terms before enrolling.

Can Extra Help lower what I pay?

Yes. In 2026, Extra Help has a $0 premium and deductible and charges up to $12.65 for a covered brand-name drug at a participating pharmacy. Bijuva still must be covered by the plan or approved by exception for that covered-drug price to apply.

Does the Medicare Prescription Payment Plan make Bijuva cheaper?

No. It can spread out-of-pocket costs for covered Part D drugs across the calendar year, but it does not reduce the total or create coverage. A Bijuva purchase outside Part D through Mayne's coupon cannot be included.

Is there a generic Bijuva?

An FDA-approved generic for Bijuva 1 mg/100 mg exists under ANDA 214293, but it is not currently marketed for routine purchase. The patent settlement announced a planned May 25, 2032 U.S. entry date, with possible earlier entry under specified circumstances.

Is Bijuva FDA-approved or compounded?

Bijuva is an FDA-approved prescription medication containing estradiol and progesterone. It is not a compounded product.

Does Bijuva still have a boxed warning?

No. The FDA approved removal of the boxed warning in February 2026. The current label still contains contraindications and warnings; removal does not mean the risks disappeared.

What if I have had a hysterectomy?

The FDA-approved patient labeling says not to use Bijuva after the uterus has been removed. Ask a clinician which regimen fits your anatomy and symptoms rather than letting plan coverage decide.

Can my plan change its drug list during the year?

Yes, within Medicare's rules. For many changes affecting a drug you are already taking, the plan must give at least 30 days' advance notice or provide notice with at least a month's supply at refill. You can request an exception.

When can I switch Medicare drug plans?

Medicare Open Enrollment runs October 15 through December 7, with changes generally effective January 1. Other enrollment windows or Special Enrollment Periods may apply depending on the coverage and qualifying event.

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Related

• Does Medicare cover HRT for menopause?
• Find My HRT Path
• How The HRT Index handles medical review