Enbrel is a medication that is used to treat various types of autoimmune diseases. It is a biologic medication approved by the Food and Drug Administration to treat rheumatoid arthritis, psoriatic arthritis, plaque psoriasis, and more.
When this medication is used it blocks tumor necrosis factor, or TNF. By blocking TNF Enbrel reduces the inflammatory response to help prevent your body from fighting itself.
If this is a drug that has been recommended to you and, a common question you likely have is “does Medicare cover Enbrel?”
In this article, we answer that question in clear, plain English. You will also find the average costs of Enbrel and other helpful info.
Does Medicare Cover Enbrel?
The short answer is no. In most cases, Original Medicare will not cover the cost of Enbrel.
Despite that, there may be some situations where you can get your costs covered. Especially if you have a Part C or Part D plan. Below we’ll take a closer look at this to see when you might be able to get Medicare to pay for your Enbrel.
Original Medicare Coverage for Enbrel
Original Medicare (Medicare Part A and Part B) does not provide coverage for Enbrel.
That is because Original Medicare mainly covers medically necessary services, equipment, and treatment rather than prescription drugs.
Prescription drug coverage may be provided by either Medicare Advantage plans or by Medicare Part D. Let’s take a look.
Part C Coverage For Enbrel
Medicare Advantage plans, namely, Medicare Part C, provides coverage for Enbrel. Medicare Advantage plans cover everything Original Medicare covers but they will offer additional benefits that Original Medicare does not.
What a Part C plan covers and how much the out-of-pocket costs are will vary depending on the specifics of your plan.
Medicare Part C plans that include prescription drug plans will provide coverage for many medications, such as Enbrel, that your healthcare provider may prescribe.
Part D Coverage For Enbrel
Medicare Part D plans also provide coverage for Enbrel. Part D is a prescription drug plan, and just like Part C, Part D plans are provided by private insurance companies.
77 percent of both Medicare Part C and Part D plans provide coverage for the medication Enbrel.
More Information on Purchasing Enbrel
Most Medicare plans restrict the amount of purchase for Enbrel a person can purchase at a time.
If you need to purchase a greater amount of Enbrel than the quantity that is allowed, Medicare may not cover it. In a case like this, you can either wait until the period has passed before refilling or contact your plan provider and ask for an exception.
Enbrel is listed as a Tier 5 drug in the Medicare drug formulary. Tier 5 medications are more expensive than Tier 1, 2, 3, and 4 medications.
Most Medicare plans also require you to have prior authorization before they provide you with medication coverage. The usage of this medication has to be for medically necessary purposes. You must contact your plan provider to get authorization.
How Much Does Enbrel Cost?
The cost of a carton containing 4 mini cartridges of 50mg Enbrel costs $9,300. This price is unlikely to vary greatly.
Additional Info on Medicare Coverage
This article is part of our series on “What does Medicare cover?”
Also, you can check out other articles in this series including: Does Medicare Cover Audiology?