Does Medicare Cover Enbrel?

Rheumatoid arthritis (RA) impacts 51 out of every 10,000 people, according to a study published in The Journal of Rheumatology. If you're among those affected by the disease, you know how the stiffness and pain associated with the condition can interfere with daily life. The condition can also cause serious problems with the skin, eyes, heart, lungs, kidneys, bones and nerves. Enbrel is a prescription medication approved by the U.S. Food and Drug Administration to treat RA symptoms and minimize the risk of health complications due to the disease. Medicare may help you pay for the cost of this beneficial drug.

Does Medicare Cover Enbrel?

Because the drug is taken at home rather than in an outpatient setting, Medicare coverage for Enbrel falls under Part D plans. GoodRx reports that 77% of Medicare prescription drug plans cover the drug as of May 2021. Medicare Part D plans are separate from original Medicare. You'll need to sign up for one through a private insurer.

What Does Enbrel Do?

Rheumatoid arthritis occurs when your immune system begins to attack your joints, giving rise to inflammation. A protein called tumor necrosis factor (TNF) drives the process. Enbrel is a type of injectable drug known as a biologic agent or biologic. It works by attaching to TNF proteins, preventing them from acting on the joints. Typically, doctors prescribe one 50-gram injection of the drug per week for the treatment of RA.

Is There a Generic for Enbrel?

The generic name for Enbrel is etanercept. As of October 2021, the FDA hasn't approved a generic version of the drug for sale in the United States.

How Much Does Enbrel Cost Per Month?

Without insurance, the retail Enbrel cost is around $9,000 as of October 2021, according to GoodRx. You may pay more or less, depending on where you live and which pharmacy fills your prescription.

What Will I Pay for Enbrel With Medicare?

Amgen, the manufacturer of Enbrel, reports that 76% of people with Medicare plans that cover the drug typically pay less than $50 per month and that the remaining 24% have an average monthly cost of about $400. Your own Enbrel cost will depend on your plan's formulary and what stage of coverage you're in.

What Is a Formulary?

A formulary establishes which drugs an insurance plan pays for. Within the formulary, drugs are divided into the following tiers:

• Tier 1 is the preferred generic drug that treats a specific condition, usually the least expensive option.
• Tier 2 contains other generic drugs for the condition.
• Tier 3 is the preferred brand name drug that doesn't have a generic version used to treat a condition.
• Tier 4 features other brand name drugs.
• Tier 5 is reserved for experimental and specialty drugs.

Generally, the higher the tier, the more you'll have to pay out of pocket for a medication. Most Medicare drug plans place Enbrel on Tier 3 or 4 because it is a brand name drug without a generic equivalent.

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What Are The Stages of Part D Coverage?

Medicare Part D plans have four stages of coverage. As you move through the stages, the amount you're likely to pay for Enbrel will vary as follows:

• Deductible stage. Before your plan begins to provide coverage, you must satisfy a deductible. Until then, you'll generally have to pay for the full cost of Enbrel out of pocket.
• Post-deductible stage. After payment of the deductible, Medicare Part D plans begin paying for a share of costs. You typically are responsible for only a copay or coinsurance during this stage.
• Coverage gap. When the combined amount that you and your insurance company have paid for prescription drugs exceeds a pre-established level, you enter the coverage gap or donut hole. For 2021, the donut hole begins at $4,130. During the coverage gap, you'll usually pay for 25% of the cost of Enbrel.
• Catastrophic coverage. Once your combined drug spending surpasses an upper limit, the coverage gap ends, and catastrophic coverage begins. In 2021, catastrophic coverage begins at $6,550 in total drug spending. Your Medicare Part D plan typically pays for most of the cost of Enbrel, leaving you with only a copay or coinsurance. Because of Enbrel's price, it's possible that your first one-month supply will place you into catastrophic coverage.

Do Medicare Advantage Plans Cover Enbrel?

Medicare Advantage Plans that include prescription drug coverage may help pay for the cost of Enbrel. Typically, you'll have to satisfy a deductible and pay a copay or coinsurance for the medication.

Is There a Cheaper Alternative to Enbrel?

The Mayo Clinic lists the following drugs as other biologic agents for treating RA:

• Abatacept (brand name Orencia)
• Adalimumab (brand name Humira)
• Anakinra (brand name Kineret)
• Certolizumab (brand name Cimzia)
• Golimumab (brand name Simponi)
• Infliximab (brand name Remicade)
• Rituximab (brand name Rituxan)
• Sarilumab (brand name Kevzara)
• Tocilizumab (brand name Actemra)

Other drugs may also be used in place of biological agents, such as:

• Corticosteroids
• Disease-modifying antirheumatic drugs (DMARDs), such as hydroxychloroquine, leflunomide methotrexate and sulfasalazine
• Targeted DMARDs, such as baricitinib (brand name Olumiant), tofacitinib (brand name Xeljanz) and upadacitinib (brand name Rinvoq)

You can explore treatment options with your doctor. Whether any of these drugs are less expensive than Enbrel depends on your Medicare drug plan's formulary.

Are There Assistance Programs for Enbrel?

Amgen provides a copay card and an assistance program for Enbrel; however, these offers aren't available for people on Medicare. Your state's Pharmaceutical Assistance programs may be able to help you pay for Enbrel if your Medicare plan doesn't cover the drug or you can't afford your copays or coinsurance.