Does Medicare Cover Humira?
Humira is the brand-name of the generic form of the drug adalimumab. It’s a monoclonal antibody that the FDA approved in 2002 to relieve pain and swelling in patients with the following autoimmune conditions:
- Rheumatoid arthritis (adults)
- Juvenile idiopathic arthritis
- Psoriatic arthritis (adults)
- Ankylosing spondylitis (adults)
- Crohn’s disease
- Ulcerative colitis
- Plaque psoriasis
- Hidradenitis supperativa
- Uveitis (certain types)
If your physician prescribes Humira, you can administer it yourself at home through easy-to-use pre-filled pens or syringes. Today, Humira is the world’s highest-selling drug, but it doesn’t work for everyone, so this is a topic you should talk about with your physician. And, because Humira is an expensive prescription medication, you might want to look into whether your Medicare benefits cover part of the cost.
Does Medicare cover Humira?
Although Original Medicare Part B (medical insurance) covers some prescription drugs, Humira isn’t one of them. For Part B coverage, the drug must be administered by a medical professional in an outpatient setting. Because you can administer Humira yourself at home, you would only get help paying for it through Medicare Part D, the prescription drug coverage.
To get coverage for Humira, you must have a prescription drug plan. Beneficiaries who have Original Medicare Parts A and/or B, can enroll in a stand-alone Part D Prescription Drug Plan (PDP) from a private insurance company that offers these types of Medicare plans.
If you have a Medicare Advantage (Part C) plan, your plan may include prescription drug coverage bundled together with your basic coverage. These plans are sometimes referred to as “MA-PDs.”
Because all Medicare Prescription Drug Plans are sold by private companies working with Medicare, they have the option to include which prescription drugs to cover. However, all Part D plans are required to include at least two medications in each of the therapeutic drug classes.
The list of drugs that a Part D plan covers is called the plan’s formulary. Formularies are then divided into tiers which carry different copayments. To get an idea of the way Medicare Part D plans work, here’s a look at the tier system:
- Tier one drugs are typically generic drugs and have the lowest copayment, in some instances this is $0.
- Tier two drugs are preferred, brand-name drugs with a medium copayment.
- Tier three drugs are non-preferred, brand-name drugs with a higher copayment.
- Tier four drugs are those that are very high-cost drugs. These have a very high copayment. Some plans label this tier as specialty drugs.
Most Medicare Prescription Drug Plans and MA-PDs categorize Humira as a specialty drug, and it can be expensive. What you pay out-of-pocket for your prescription of Humira depends on how much your Part D plan charges for the copayment and where you purchase the drug.
Without Medicare Part D coverage, the national average cost for a one-month supply of Humira is around $7,400.00. This means it would cost over $89,000.00 per year.
Taking these costs into consideration, if you rely on Humira for treatment of a medical condition, it would be valuable to have Medicare prescription drug coverage.