Does Medicare Cover Enbrel?

Enbrel is a popular specialty biologic medication used to treat different types of autoimmune conditions, like rheumatoid arthritis. The medication helps block damage from an overactive immune system.

Most Medicare Part C and Part D plans cover Enbrel. However, since this medication is considered a specialty drug, you may have a higher copay depending on your plan.

Let’s take a closer look at how Medicare plans covers Enbrel and what you may have to pay for the medication.

Does Medicare cover Enbrel?

Enbrel is covered by many Medicare Part D plans for self-injection at home. Coverage and costs depend on specific plans, based on where you live.

Part D plans are Medicare-approved private insurance plans that help cover prescription drug costs. If you’re eligible for original Medicare, you’re eligible for Part D. Original Medicare is made up of Part A (hospital insurance) and Part B (outpatient insurance),

In every state, there are many different plan options to choose from. Premiums, coverage, and out-of-pocket costs vary from plan to plan.

All Part D plans have a formulary. This is a list of covered medications arranged in a tiered format.

Most companies have five or six tiers for their covered medications, with lower- cost medications on tier 1 and 2. Usually, the higher the tier your medication falls under, the more you’ll pay for it.

Medicare requires plans to include at least two medications from each class, like the biologic medications for autoimmune conditions.

Enbrel is categorized as a specialty medication and is in the higher tiers (5 or 6). This means your out-of-pocket costs for it will be on the higher end as well.

It’s important to compare the cost of Enbrel under different Medicare Part D plans and with other medication options. Talk with your doctor about your choices, and use Medicare’s plan comparison tool to find the best options for your needs and budget.

Does Part C (Medicare Advantage) cover Enbrel?

Medicare Part C, or Medicare Advantage, plans include coverage for the same services as Part A, Part B, and often Part D (prescription drug coverage).

These plans are sold by private insurance companies and are approved by Medicare. Part C plans typically provide additional coverage not included in original Medicare, like vision, dental, and other wellness benefits.

Some Part C plans may have restrictions on using in-network providers, such as pharmacies and doctors.

Types of plans, coverage, and costs all vary depending on where you live and the amount of coverage you need. Part C does allow you to bundle most of your healthcare needs into one plan.

It’s a good idea to check which plans cover your medications, including Enbrel, and what your cost might be. You can either call the plan provider directly, check with your pharmacy, or use Medicare’s plan finder tool to narrow down specific drug coverage and cost.

What about Medigap coverage?

Medigap, or Medicare supplement insurance, can help you pay for some original Medicare costs like:

• coinsurance
• copayments
• deductibles

There are 10 plans to choose from depending on where you live.

New Medigap plans no longer offer prescription drug coverage. If you have a plan from before 2006, however, you may still have medication benefits on your plan.

Check with your plan on specific coverage and drug coverage benefits.

How much does Enbrel cost?

Enbrel can be expensive since it’s a specialty medication in the higher tiers of a drug plan’s formulary, with no generic version available.

Because chronic conditions like rheumatoid arthritis and other autoimmune conditions continue throughout your life, medications like Enbrel need to be used long term for symptom management.

Cost can be a major consideration in medication choice and continuing therapy for many people with Part D plans. Most Part C and Part D plans have at least two medications in each class, and costs may differ for the covered medications.

A 2015 study on the use of biologic medications by Medicare recipients with psoriasis found that those without assistance from the Medicare Extra Help program were 70 percent less likely to use biologics than those enrolled in the program. Extra Help eligibility is based on income and financial need.

According to Amgen, the manufacturer of Enbrel, the average list price of the medication for 50-mg weekly dose is $1,389.24.

This is the typical recommended dose for adults with rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. The dose for plaque psoriasis is 50 mg twice weekly for the first 3 months, then 50 mg weekly after that.

What is Enbrel?

Enbrel is a biologic medication in the tumor necrosis factor alpha inhibitors category. It helps stop your body’s immune system from attacking itself to reduce damage caused by an overactive immune response, such as inflammation.

Enbrel is FDA approved to treat the following conditions:

• moderate to severe rheumatoid arthritis
• moderate to severe psoriatic arthritis
• moderate to severe plaque psoriasis
• active polyarticular juvenile idiopathic arthritis
• ankylosing spondylitis

The most common side effects of Enbrel include:

• injection site reactions, like redness, pain, swelling, or itching
• diarrhea
• risk of infections

Call 911 right away if you think you’re having an allergic reaction to Enbrel. Signs of an allergic reaction may include:

• severe rash
• difficulty breathing
• swelling of your face

Talk with your doctor about risks of Enbrel and your past medical history. Also let your doctor know about any other medications you’re currently taking (over the counter, prescription, or dietary supplements) to avoid side effects or interactions with Enbrel.

Avoid any live vaccines while you’re taking Enbrel or other biologics or biosimilar medications. The vaccines may not work as well to protect you.

The takeaway

Enbrel is a biologic medication that’s available as an injectable solution for self-administration. It can be used to treat various autoimmune conditions, such as moderate to severe rheumatoid arthritis.

Although no generics are available for Enbrel, some other biosimilar options are available. If you need help affording Enbrel, there are savings programs for Medicare recipients who qualify based on financial need.

Since autoimmune conditions are chronic and require long-term symptom management, discuss your concerns about medication costs with your doctor. It’s important for your doctor to understand this when making treatment recommendations in order to meet all your needs.

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