by Russell Noga | Updated February 1st, 2024
If you’re seeking information on Medicare Humira coverage, you’ve come to the right place. This guide provides clear insights on how Medicare Part D, Advantage, and Supplement plans handle Humira prescriptions, what costs you might face, and the essential steps to obtain coverage. Read on to simplify your journey through Medicare’s offerings and maintain your health without overwhelming expenses.
Key Takeaways
- Medicare provides coverage for Humira through Medicare Part D, Medicare Advantage (Part C), and Medicare Supplement Plans (Medigap), which can vary greatly in terms of costs and coverage levels.
- Obtaining Humira with Medicare coverage entails a process that includes obtaining a prescription from a doctor, prior authorization from Medicare, and finding a participating pharmacy to fill the prescription.
- The costs of Humira under Medicare can be influenced by factors such as the type of Medicare plan, the prescribed dosage and frequency, and the specific condition being treated, with various financial assistance programs available to help manage these expenses.
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Medicare Coverage for Humira: The Basics
Humira, a biologic medication, is often prescribed for the treatment of autoimmune diseases including rheumatoid arthritis and Crohn’s disease. The objective of Medicare coverage for Humira is to enhance the affordability and accessibility of this medication for individuals who need it.
Several Medicare options are available for those wondering, “does Medicare cover Humira?” These options include Medicare Part D, Medicare Advantage (Part C), and Medicare Supplement Plans.
Medicare Part D
Medicare Part D is a federal program designed to offer prescription drug coverage, encompassing medications such as Humira, with different costs and coverage levels based on the selected Medicare Part D plan. This coverage does come at a cost, often surpassing $5,000 per month, but it provides a significant relief for beneficiaries who qualify, typically covering 50% of the cost of Humira.
Medicare Advantage (Part C)
Medicare Advantage (Part C) is an alternative to traditional Medicare that offers coverage for Humira. However, as with Medicare Part D, the specifics of coverage and the associated costs can vary greatly among individual Medicare Advantage plans. A Medicare Advantage plan can include additional benefits such as lower copays or coinsurance for generic drugs, although these specifics can vary depending on the plan.
The typical expense for individuals receiving Humira under Medicare Advantage (Part C) can vary between $6,000 and $7,000, although this amount may fluctuate depending on the details of the plan offered by a private insurance company.
Medicare Supplement Plans
Medicare Supplement Plans, also known as Medigap, are a form of medical insurance designed to assist in covering out-of-pocket expenses related to medical treatments, including copays and coinsurance for medications like Humira, which are manufactured by drug companies. However, the coverage of Humira under these plans can be influenced by factors such as whether it is administered in an outpatient setting or self-administered at home, and whether it is covered by Medicare Part B or Part D.
How to Obtain Humira Through Medicare
Once you’ve grasped the basics of Medicare coverage for Humira, you need to learn the process of obtaining Humira through Medicare. This involves:
- Consultation with a clinician who can prescribe the medication online or provide a refill.
- After the prescription is issued, you can collect the medication from your preferred pharmacy.
- Remember, obtaining Humira requires prior authorization, which means your prescriber must communicate with your Medicare prescription drug plan before the medication is released to you.
Lastly, you can identify participating pharmacies that accept Medicare for Humira by consulting Medicare Part D, the prescription drug plan of Medicare.
Prescription from Your Doctor
Getting a prescription for Humira involves the following steps:
- A healthcare provider must furnish a comprehensive description of the patient’s condition and rationale for selecting Humira as the preferred treatment.
- The prescription must be forwarded to the patient’s Medicare Part B provider for assessment.
- The prescription will be evaluated to determine if the patient qualifies for coverage.
The prescription must include thorough Prescribing Information and a Medication Guide to ensure Medicare coverage for Humira.
Prior Authorization Requirements
Prior authorization entails the demonstration of medical necessity for specific medications prior to their coverage by Medicare plans. For Humira, prescribers have the option to contact 1-866-488-5995 for Medicare requests or submit the request through online channels, fax, or phone. It’s important to note that Humira is classified as a specialty medication, and the majority of Medicare prescription drug plans do require prior authorization for it.
Once the necessary medical information is provided, it usually takes a few days for prior authorization to be granted.
Finding a Participating Pharmacy
Identifying a participating pharmacy that accepts Medicare coverage for Humira is a vital step in the process. Patients may utilize the Medicare website to conduct a search for pharmacies within their vicinity that are willing to accept Medicare Part B coverage for Humira.
Additionally, online pharmacies have the capability to accept Medicare coverage for Humira.
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Factors Affecting Humira Coverage Costs
Comprehending the factors that influence Humira coverage costs is essential for effective healthcare expense management. The cost of Humira coverage can vary based on the type of Medicare plan, the prescribed dosage and frequency, and the particular condition being treated.
Plan Type and Coverage
The kind of Medicare plan chosen can greatly influence the cost of Humira. Coverage for Humira is primarily provided by Medicare Part D and Part C, with occasional coverage offered by Part B in rare instances. However, the coverage for Humira may differ among various Medicare plans. Part C, or Medicare Advantage, plans and Medicare Supplement Plans may offer coverage for Humira, but the specifics of coverage and associated costs can differ considerably. Therefore, it is crucial to check for any available assistance programs and carefully examine the plan’s formulary to ensure that Humira is included.
Out-of-pocket limits on Medicare plans can also significantly impact the costs of Humira, given the potentially high cost of the medication, which can exceed $5,000 per month.
Dosage and Frequency
The cost of Humira under Medicare may fluctuate based on the prescribed dosage, with estimates suggesting a range of $5,168 to $5,196 in 2019. The frequency of dose escalation can also impact the total amount reimbursed by Medicare for the treatment.
For instance, a carton containing two subcutaneous kits of 10 mg/0.1 mL may exceed $8,000 in cost, whereas a supply of two subcutaneous kits of 40 mg/0.4 mL may be priced at approximately $7,295. Modifying the frequency of Humira administration can be a cost-saving strategy, for example by increasing the dosage to once a week instead of every two weeks.
Condition Treated
The specific condition being treated can also affect the cost of Humira. Under Medicare Part B, Humira is covered for the treatment of specific conditions such as rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. The coverage costs are influenced by the particular condition being treated with this medication.
For instance, higher initial doses needed for conditions such as Crohn’s disease may result in increased costs.
Financial Assistance Programs for Humira Costs
Financial assistance programs can provide a lifeline for many individuals struggling to afford the cost of Humira. Several programs offer significant financial assistance, including AbbVie’s Patient Assistance Foundation, Medicare Extra Help, and Medicaid.
AbbVie’s Patient Assistance Foundation
AbbVie’s Patient Assistance Foundation offers a beacon of hope for qualified patients, covering all expenses related to the medication. To be eligible, individuals must not have prescription coverage for Humira, including those with Medicare Part D.
The process for applying for financial assistance involves filling out and submitting the provided application with the help of their healthcare provider.
Medicare Extra Help
Medicare Extra Help, also referred to as the Part D Low-Income Subsidy, is a federal initiative designed to assist individuals with constrained income and resources in mitigating their Part D expenses, particularly for prescription medications such as Humira. To qualify, individuals must reside in the United States, be enrolled in or eligible for a Part D prescription drug plan, and satisfy specific income and resource thresholds.
The program offers substantial support for Humira prescription drug costs, encompassing essential expenses such as deductibles and copays, and limiting the maximum cost for brand name drugs, including Humira, to $8.95.
Medicaid
Medicaid offers coverage for outpatient prescription drugs to all eligible individuals, providing assistance in managing the costs of medications such as Humira. In contrast to Medicare prescription drug coverage, the program offers medical assistance based on low income and limited assets.
However, there may be specific coding requirements for drugs such as Humira, which have multiple routes of administration. Prior authorization for Humira under Medicaid requires completion of a form with all necessary details, along with proper signing and dating.
Tips for Reducing Out-of-Pocket Expenses for Humira
Once you understand Medicare coverage for Humira and the range of available assistance programs, it’s beneficial to learn some practical strategies to reduce your out-of-pocket expenses for Humira.
These include choosing the right Medicare plan for medicare beneficiaries, applying for available discounts and rebates, and maximizing the benefits from your Medicare plan.
Choosing the Right Medicare Plan
Selecting the appropriate Medicare plan is key, as it can greatly minimize out-of-pocket costs for Humira. It is essential to carefully review the ‘Evidence of Coverage’ (EOC) and ‘Annual Notice of Change’ (ANOC) when assessing Medicare plans for Humira coverage.
Verifying whether Humira is included in the plan’s formulary is of great significance as it guarantees coverage of the medication by that specific Medicare plan, thereby directly impacting the individual’s out-of-pocket expenses for the medication.
Applying for Discounts and Rebates
Applying for available discounts and rebates can help lower the cost of Humira. Eligible commercially insured patients can utilize the Humira Complete Savings Card to pay as little as $5 per monthly prescription. The HUMIRA Complete Prescription Rebate provides the opportunity to obtain Humira at a reduced price if the pharmacy does not accept the savings card or if the patient is ineligible for instant savings at the pharmacy.
To apply for these discounts and rebates, patients can sign up online at HUMIRASavingsCard.com, fill out an enrollment form, or contact the support line at 1-800-4HUMIRA.
Maximizing Benefits from Your Plan
Maximizing the benefits from your Medicare plan can also help minimize out-of-pocket expenses for Humira. It is advisable to carefully consider and select a plan with comprehensive drug coverage and thoroughly examine the plan’s formulary.
Exploring any additional savings programs or assistance options provided by Humira or Medicare can also prove beneficial.
Safety and Side Effects of Humira
Although Humira provides substantial benefits, it’s important to be aware of the safety issues and potential side effects that may arise from its use. Humira has been linked with an elevated likelihood of developing lymphoma, skin cancer, and leukemia. In addition, it can lead to serious infections such as sepsis, tuberculosis, and histoplasmosis. Safety protocols, including testing for tuberculosis, are implemented prior to commencing Humira treatment. If a severe infection occurs, the administration of Humira is typically discontinued.
FDA Warnings
Humira carries FDA boxed warnings due to the heightened risk of severe infections that may result in hospitalization or mortality, such as tuberculosis and pneumonia, and the potential susceptibility to malignancies such as lymphoma. These warnings highlight the need for patients and healthcare providers to remain diligent in monitoring for symptoms of serious infections and cancers. If a serious infection occurs, the administration of Humira should be promptly discontinued.
Serious Infections
Humira elevates the risk of serious infections by modulating the immune system and reducing the body’s capacity to combat infections. These infections may encompass those caused by viruses, fungi, bacteria, and conditions such as tuberculosis (TB). It’s therefore crucial for patients to promptly seek medical attention if they experience symptoms such as persistent fever, bruising, bleeding, and pallor.
Healthcare providers are advised to adhere to the CDC recommendation to conduct screening for tuberculosis (TB) before initiating therapy with Humira and to closely monitor patients for signs and symptoms of infection both during and after treatment with Humira.
Cancer Risk
Humira has been linked with an increased risk of certain types of cancer. The overall risk of malignancies associated with adalimumab, the active ingredient in Humira, is not elevated in comparison to the general population. However, risk factors associated with the development of cancer from Humira encompass high RA disease activity, a previous history of cancer, and the use of TNF blockers.
Both children and adults taking Humira face a potential increase in the risk of developing lymphoma or other cancers.
Conditions Treated by Humira
Humira, a multifaceted medication, is prescribed for a variety of conditions, including:
- Rheumatoid arthritis
- Psoriatic arthritis
- Ankylosing spondylitis
- Crohn’s disease
- Ulcerative colitis
- Plaque psoriasis
It is effectively used to manage these diverse health conditions. It functions by suppressing the excessive production of TNF (alpha) in the body, leading to a reduction in inflammation and alleviation of pain.
Rheumatoid Arthritis
Rheumatoid arthritis, a chronic inflammatory disorder, predominantly affects the joints. Humira, classified as a disease-modifying antirheumatic drug (DMARD), aids in the management of moderately to severely active rheumatoid arthritis by selectively binding and inhibiting the inflammatory cytokine tumor necrosis factor (TNF)α. This action can lead to:
- Reduction in joint pain
- Reduction in joint swelling
- Reduction in joint stiffness
- Prevention of additional joint damage
Crohn’s Disease
Crohn’s disease, an inflammatory bowel disease, triggers inflammation in the digestive tract, resulting in symptoms like abdominal pain, severe diarrhea, fatigue, weight loss, and malnutrition. Humira aids in the treatment of Crohn’s Disease by blocking a source of inflammation and binding to TNF protein molecules, which are associated with the disease.
The initial prescribed dosage of Humira for the treatment of Crohn’s disease is 160 mg on Day 1.
Ankylosing Spondylitis
Ankylosing spondylitis, an inflammatory disorder, causes inflammation in the spine’s joints and ligaments, leading to stiffness and discomfort, especially in the lower back. Humira operates by specifically targeting and inhibiting a particular source of inflammation that exacerbates the symptoms of Ankylosing Spondylitis.
Empirical data from clinical trials indicates that Humira (adalimumab) is efficacious in enhancing spinal pain and function in individuals with Ankylosing Spondylitis. The prescribed dosage of Humira for Ankylosing Spondylitis is 40 mg administered every other week.
Summary
In conclusion, understanding Medicare coverage for Humira is crucial for managing the costs associated with its use. While the cost of Humira can be significant, various Medicare plans and financial assistance programs can help make the medication more affordable. However, it’s also essential to understand the potential safety concerns and side effects associated with its use. By being well-informed about these aspects, you can make the best decisions for your health and finances.
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Frequently Asked Questions
Is Humira covered by Medicare?
Yes, Medicare provides coverage for Humira, usually through Medicare Part D, which is the prescription drug coverage. You can compare and enroll in a Medicare prescription drug plan online through MyRxPlans.com.
Does Medicare pay for biologic injections?
No, Medicare Part B generally covers only drugs that are not usually self-administered, including covered preventive vaccines. Therefore, it may cover biologic injections under certain circumstances.
Is Humira a Tier 4 drug?
Yes, Humira is typically classified as a Tier 5 drug in Medicare Part D plans, which means it may cost more compared to drugs in lower tiers.
What is the out of pocket cost for Humira?
The out-of-pocket cost for Humira can vary depending on your prescription drug coverage. The list price for a month’s supply is $6,922, but patients typically don’t pay that much out of pocket every month. Instead, it depends on their insurance coverage.
What is Humira and what conditions does it treat?
Humira is a biologic medication used to treat various autoimmune diseases such as rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn’s disease, ulcerative colitis, and plaque psoriasis.
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Russell Noga is the CEO and Medicare editor of Medisupps.com. His 15 years of experience in the Medicare insurance market includes being a licensed Medicare insurance broker in all 50 states. He is frequently featured as a featured as a keynote Medicare event speaker, has authored hundreds of Medicare content pages, and hosts the very popular Medisupps.com Medicare Youtube channel. His expertise includes Medicare, Medigap insurance, Medicare Advantage plans, and Medicare Part D.