Enbrel is a medication that doctors use to treat various autoimmune conditions. Medicare coverage of this drug depends on the type of plan.

Enbrel is a biologic medication, which means it is made from a live organism. It is available only by prescription.

Medicare may offer coverage for biologics through Medicare Advantage (Plan C) and Medicare Plan D. However, costs and coverage can vary among plans.

Read on to learn more about what coverage Medicare may offer for Enbrel. This article also looks at the costs of the medication and financial assistance.

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Medicare classifies Enbrel as a specialty drug and places it in a higher cost category. As a result, Medicare may cover it at a reduced rate.

Generally, Medicare Advantage (Part C) and Medicare Part D provide insurance coverage for Enbrel.

Part D

Medicare Part D offers coverage for prescription medications. A person who is eligible to enroll in original Medicare may also get the optional Part D plan. Medicare-approved private companies administer Part D plans.

Not all Part D plans cover the same medications, but Medicare requires each plan to cover a minimum of two medications in each class. Each individual Part D plan provides a list, called a formulary, of covered medications.

The formulary divides medications into levels of coverage called tiers, with tiers 1 and 2 containing the lower cost drugs.

In most cases, the higher the tier, the more a person pays for the medications. The specialty tier is the highest tier.

Learn more about Medicare Part D.

Medicare Advantage

Medicare Advantage plans may cover Enbrel. Most Medicare Advantage plans include Medicare Part D drug coverage.

However, the coverage and costs vary among plans. Some plans may also have restrictions on using their in-network providers.

Private insurance companies that Medicare has approved are responsible for managing these plans. They may provide additional coverage that original Medicare does not include, such as dental, vision, and hearing care.

Learn about choosing a Medicare Advantage plan.

According to Enbrel’s manufacturer Amgen, the list price, or wholesale price of a 50-milligram (mg) weekly dose of Enbrel is $1,850.46.

Most individuals do not pay the list price for Enbrel. However, Medicare’s percentage coverage of this cost varies depending on several factors, including the specific plan and the person’s location.

People who may need help paying for Enbrel have several options.

Medigap

Medigap is supplemental insurance coverage to help pay costs that original Medicare does not cover, such as copays, coinsurance, and deductibles.

Private companies administer Medigap plans. There are 10 different plans to choose from depending on where a person lives.

Newer Medigap plans no longer provide coverage for prescription drugs, although plans selected before 2006 may still provide medication coverage.

Medicare savings programs

Medicare savings programs (MSPs), which are state-operated and federally funded, provide cost assistance to qualified individuals.

However, the four savings programs cover the costs associated with original Medicare, not prescription drugs.

Medicare Extra Help program

The Medicare Extra Help program provides coverage for some expenses relating to Part D medications, including monthly premiums, copays, and coinsurance.

Some people automatically qualify for the program, including individuals who get both Medicaid and Medicare and those who receive Social Security benefits.

Medicare sets an income and resource limit for eligibility. For 2024, there is an income limit of $22,590 for a single person or $30,660 for a married couple. There is also a resources, or assets, limit of $17,220 for a single person or $34,360 for married people living together.

Coupons

Coupons may help people pay for named prescription drugs, including Enbrel. Coupons can include:

However, a person cannot use a drug coupon in combination with original Medicare, Advantage plans, or Part D.

Learn more about coupons and Medicare.

Medicaid

Medicaid provides health insurance coverage to certain people, including:

  • children
  • adults with limited income
  • pregnant people
  • adults with disabilities

Both the state and the federal government fund Medicaid.

Federal law states that prescription drug coverage is optional for Medicaid. However, currently, all states provide prescription drug coverage to Medicaid recipients. For information on applying for Medicaid, individuals can visit the Medicaid website.

What is the average monthly cost of Enbrel?

According to the manufacturer’s website, a 50-milligram (mg) weekly dose of Enbrel has a list price of $1,850.46. This means that a 4-week, or roughly 1-month, supply of weekly doses costs around $7,401.84. However, an individual is unlikely to pay this full cost. A person can contact their health insurance provider to find out about what coverage they offer for Enbrel.

Is Enbrel a tier 3 drug?

Enbrel is a specialty tier drug. This is higher than a tier 3 drug.

Does Medicare pay for biologic injections?

Medicare may pay for biologic injections through Medicare Part D or Medicare Advantage (Part C). Part B might cover biologics if it is necessary for a medical professional to administer them.

Enbrel is a biologic medication that doctors may recommend for the treatment of certain autoimmune conditions. Usually, Medicare Part D and Medicare Advantage plans offer coverage for the medication.

As Enbrel is a specialty drug, Medicare Part D may cover it at a more reduced rate compared with other medications.