Does Medicare Provide Coverage for Prescription HUMIRA?

In this article...
  • Discover whether Medicare plans cover some of the costs for the prescription drug HUMIRA, and find out how much you can expect to pay each month with insurance.

If you're living with certain types of arthritis or Crohn's disease, your doctor may prescribe HUMIRA to alleviate your symptoms. The prescription can be expensive, especially if you take the drug long-term, so it's important to find Medicare plans that offer partial or full prescription drug coverage. Before you commit to a plan, make sure you understand how and when it helps you pay for HUMIRA

Does Medicare Cover HUMIRA?

Original Medicare Part A and Part B do not provide prescription drug coverage for medications like HUMIRA. However, you can buy Medicare Part D or Medicare Advantage plans with drug coverage that offer coverage for HUMIRA.

If you have Original Medicare, it's worth your time to investigate the Medicare Part D prescription drug plans that are available in your area. Many of these plans offer coverage for HUMIRA. Certain Medicare Advantage plans also come with drug coverage to help you pay for HUMIRA.

How Much Does HUMIRA Cost?

HUMIRA is typically considered a Tier 5 specialty drug, which means it's usually very expensive. While your exact costs will vary based on the dosage, how you pay and the specific type of HUMIRA, you can expect the drug to cost between $6,000 and $7,000 or more per month.

If you have a Medicare Part D plan — or a Medicare Advantage plan with drug coverage — you'll pay the full cost for a HUMIRA prescription up to your deductible amount (if you haven't met it already for the year). For 2022, insurance companies can legally set the deductible as high as $480. However, your plan may offer a lower deductible. After that, you'll be responsible for the copay that's listed in your plan. This amount depends on your plan terms, location and the price of the drug at your chosen pharmacy.

Once you and your provider have paid $4,430 in total toward prescription drugs, you enter what's known as the coverage gap. At this point, you'll typically be responsible for a copay of 25%; Part D covers the remaining 75%. This is an important factor to consider when you need coverage for an expensive medication like HUMIRA — that 25% payment can translate to a significant monthly cost until you reach the next benefit year. If you're part of the Extra Help program, you may qualify for lower copays and won't be affected by the coverage gap.

Keep in mind that these coverage types apply when you administer HUMIRA yourself. If your doctor needs to give you the medication in the office, there's a chance it could be covered under Medicare Part B.

Are There Other Ways To Make HUMIRA More Affordable?

If you need additional help paying for a HUMIRA prescription, there are many other ways to save money on prescription drugs. Medicaid, for example, typically covers the bulk of prescription drug expenses; you may be responsible for a small copay.

Your state likely has a State Pharmaceutical Assistance Program (SPAP) that may be able to help defray the costs of HUMIRA. Other options include coverage from an employer and COBRA. If you're eligible for the Federal Employee Health Benefits (FEHB) Program, your coverage likely provides prescription drug coverage. You may also qualify for additional help through the Indian Health Service, TRICARE or the Department of Veterans Affairs (VA).

When you don't have Medicare or another type of insurance, a prescription discount card may help reduce the price of HUMIRA slightly. If you have commercial or employer-sponsored insurance, a better option may be the HUMIRA Complete Savings Card, which can reduce costs to as low as $5 per month. Your actual discount will vary based on the type of coverage you have and the type of HUMIRA you take.

What Is HUMIRA?

HUMIRA is the brand name for the drug Adalimumab. This prescription medication comes in an injection pen or a syringe. Most people require two pens or syringes per month.

Doctors often prescribe HUMIRA to treat rheumatoid arthritis, Crohn's disease, psoriatic arthritis and ankylosing spondylitis. The Food and Drug Administration (FDA) has also approved HUMIRA to treat a range of additional conditions, including pediatric uveitis, juvenile idiopathic arthritis, ulcerative colitis, plaque psoriasis and hidradenitis suppurativa.

HUMIRA is part of the TNF blocker family of medications. When the drug is injected into your system, it blocks the tumor necrosis factor (TNF) molecules that can cause inflammation and pain. Since inflammation is the culprit behind many symptoms of arthritis and Crohn's disease, you may experience less discomfort as a result.

Is There a Generic Version of HUMIRA?

As of 2022, HUMIRA is the only way to get Adalimumab. However, in October of 2021, the FDA approved a biosimilar drug called Cyltezo — the first of its kind. Cyltezo is approved to treat many of the same conditions as HUMIRA. It's expected to be available in 2023.

Biosimilar products are not the same as generic, but they do tend to be cheaper than the reference drug. What's more, the FDA allows pharmacists to substitute the biosimilar drug for the original brand-name drug without a new prescription.

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