Does Medicare Cover Enbrel? 

Millions of people in the United States are currently living with autoimmune diseases like rheumatoid arthritis, psoriatic arthritis, plaque psoriasis, ankylosing spondylitis, and others. Even though there are many different types of autoimmune conditions, they often cause a range of common symptoms that people live with unless they get treatment:

  • Swelling and pain in the joints
  • Skin problems
  • Extreme fatigue
  • Abdominal pain and cramps
  • Problems with digestion
  • Fevers
  • Swollen glands

One of the most common FDA-approved biological medical products used to treat certain immune diseases like those listed above is etanercept, which is available under the brand name drug Enbrel. 

Enbrel works by blocking tumor necrosis factor (TNF), which is responsible for regulating the immune response in the body’s organs. And, because autoimmune diseases occur when the body has an overactive autoimmune response, taking a drug like Enbrel can treat the disease and ease the related symptoms. 

As of now, Enbrel is prescribed for the treatment of the following autoimmune diseases:

  • Rheumatoid arthritis that is moderate to severe
  • Polyarticular juvenile rheumatoid arthritis (moderate to severe)
  • Psoriatic arthritis
  • Ankylosing spondylitis
  • Plaque psoriasis (moderate to severe)

If your physician has prescribed Enbrel, your Medicare coverage might help you cover a portion of the expenses.

Does Medicare cover Enbrel prescriptions? 

Enbrel comes in a pre-filled disposable autoinjector that you can administer to yourself subcutaneously (just under the skin). You can inject Enbrel into your thigh or abdomen or have someone else inject it into your upper arm. Because Enbrel can be self-administered, it isn’t covered by Medicare Part B (medical insurance). To get coverage, you must have a Medicare prescription drug plan. 

If you plan to enroll in Original Medicare Parts A and B, you can purchase a stand-alone Medicare Part D plan for prescription drug coverage during your initial enrollment period. 

If you plan to enroll in a Medicare Advantage (Part C) as an alternative to Original Medicare Parts A and B, you might want to consider enrolling in a plan that includes prescription drug coverage. 

If you’re already enrolled in a Medicare Advantage plan, but it doesn’t include Part D coverage, you can switch to a plan that does during Open Enrollment Period, from October 15 through December 7, or during the Medicare Advantage Open Enrollment Period from January 1 to March 31st. During these periods, you can also switch to Original Medicare Parts A and B and purchase a separate Part D plan. 

How much will Enbrel cost under Part D?

Because all prescription drug plans are sold by private insurance companies that work with Medicare, they have some options regarding the drugs they include on their formularies (lists of covered drugs). Today, most Part D plans cover Enbrel, but you should check the plan’s formulary to be sure. 

How much you pay as a copayment for Enbrel depends on which tier it’s been categorized. Most plans have four or five drug tiers and the lower the tier, the smaller the copayment. For example, generic drugs are tier-one drugs with a $0 or very low copayment. Enbrel is typically categorized as a specialty (tier five) drug and carries the highest copayment which is approximately 25 to 33 percent of the retail cost of the drug. 

How much does Enbrel cost without Medicare coverage? 

If you don’t have insurance coverage for Enbrel, your final cost will depend on where you purchase your prescription and what your dosage is. Today, the national average price for a month’s supply of four Enbrel autoinjectors containing 50 mg is around $8000.

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