Enbrel is a medication that doctors use to treat various autoimmune diseases. Medicare coverage of this drug depends on the type of plan.
This article describes Enbrel and the conditions that the Food and Drug Administration (FDA) have approved it to treat. It then looks at Medicare coverage, examining the costs and the possible sources of financial assistance to help pay them.
Enbrel is a biologic medication, which means that it is made from a live organism. It is available only by prescription.
Enbrel contains the active ingredient etanercept, and the FDA have approved it to treat five autoimmune diseases:
- Ankylosing spondylitis in adults: This condition is a form of arthritis that affects the spine.
- Plaque psoriasis in adults and children aged 4 years and older: People with this condition develop scaly patches on the skin.
- Psoriatic arthritis in adults: Individuals with psoriasis may develop this form of arthritis.
- Polyarticular juvenile idiopathic arthritis in children aged 2 years and older: This form of arthritis only develops in children.
- Rheumatoid arthritis in adults: This autoimmune disorder occurs when the body’s immune system mistakenly attacks the joints throughout the body.
People with inflammatory diseases, such as those above, produce excess tumor necrosis factor (TNF), which may trigger the immune system response that causes the symptoms. Enbrel blocks TNF, which may reduce the inflammatory response.
Currently, there is no generic form of Enbrel. It is only available as a brand name medication.
Federally funded Medicare offers several plans that provide coverage for different areas of healthcare. It is available for older people in the United States and some younger people with certain conditions or disabilities.
The program consists of:
- Part A, which offers coverage for hospital costs, including acute care hospitals, rehab facilities, and mental health hospitals.
- Part B, which is medical insurance and also covers certain preventive care.
- Part C, also known as Medicare Advantage, which is an alternative to original Medicare (Part A and Part B) and may include additional benefits.
- Part D, which covers prescription drugs.
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.
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, including biologic medications for autoimmune diseases. 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. Enbrel is a specialty drug that Part D plans list as a tier 5 medication.
More than 75% of Medicare Advantage plans cover Enbrel, although 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.
According to Enbrel’s manufacturer, Amgen, the list, or wholesale, price of a 50-milligram weekly dose of the medication is $1,389.24. Medicare’s percentage coverage of this cost varies depending on several factors, including the specific plan and the person’s location.
According to research in the journal Rheumatoid Arthritis, 2013 data showed that most Part D plans required people to pay a coinsurance averaging 29.6% of the costs of the prescribed biologic.
People who may need help paying for Enbrel have several options, including the ones below.
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 saving programs
Medicare savings programs (MSPs), which are state-operated and federally funded, provide cost assistance to qualified individuals. But the four savings programs cover the costs associated with original Medicare, not prescription drugs.
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 2021, there is an income limit of $25,860 for a married couple and $19,140 for a single person. There is also a resources, or assets, limit of $29,520 for married people living together and $14,790 for a single person.
Coupons, including pharmacy discount cards, manufacturer or pharmacy coupons, and discount drug company coupons, may help people pay for named prescription drugs, including Enbrel.
However, a person cannot use a drug coupon in combination with original Medicare, Advantage plans, or Part D.
Medicaid provides health insurance coverage to certain people, including children, adults with limited income, pregnant people, and 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.
Enbrel is a medication that people take to treat certain autoimmune diseases. 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.
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