Many Medicare drug plans cover generic epinephrine auto-injectors, and some may also cover EpiPen. Medicare coverage through a Part D prescription drug plan depends on the plan details, and other factors.
Auto-injectors inject a set dose of epinephrine into a person experiencing a life-threatening allergic reaction.
This article will discuss EpiPens, epinephrine, allergic reactions, and how the auto-injectors are used. It also looks at Medicare coverage, costs, and possible financial aid.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
EpiPen is a brand name for a device that injects epinephrine into a person having a severe allergic reaction that may be life-threatening. It is manufactured by Pfizer, although a company called Mylan owns the brand. It also provides authorized generic devices.
Healthcare providers prescribe epinephrine auto-injectors to people at risk of a severe allergic reaction, which is also known as anaphylaxis or anaphylactic shock. Anaphylaxis can happen quickly, and a person concerned about serious allergic reactions typically keeps an epinephrine injector with them at all times, at home and at work.
A person can self-administer the injection, or another person can give it. Someone gives the injection by removing a safety cap from the device and then pressing the tip firmly against a person’s outer thigh until the device clicks, injecting the medicine.
After receiving an epinephrine injection, the person should go to an emergency facility for further medical care.
EpiPen devices expire at the end of an indicated month, and a person can use this online tool to get expiry alerts by email or text messages.
Epinephrine, also called adrenaline, is a naturally occurring hormone in the body. Artificial epinephrine is used as a medication for allergic reactions.
When a person gets epinephrine, the medication helps increase blood pressure by narrowing the blood vessels and helps them breathe more freely by opening the airways.
Read more about epinephrine here.
What is anaphylaxis?
Anaphylaxis is a life-threatening allergic reaction to an allergen, and can develop quickly after exposure.
During anaphylaxis, the body releases chemicals that cause blood vessels to open wider and airways to constrict. As a result, a person’s blood pressure drops, and they have trouble breathing.
There are several common triggers and symptoms of allergic reactions, including life-threatening anaphylaxis.
Read more about anaphylaxis here.
Common triggers
Common triggers of a severe allergic reaction include:
- food
- medication
- insect stings
- latex
Common symptoms
Symptoms of anaphylaxis include:
- difficulty breathing
- hives
- swelling
- hoarse voice
- abdominal pain
- nausea or vomiting
- fast heart rate
- low blood pressure
- dizziness
- fainting
- a feeling of doom
How does epinephrine work?
Epinephrine attaches to receptors in the body that help reverse the allergic reaction. Blood vessels constrict, which can bring blood pressure back up, and airways relax, which can improve breathing.
Medicare Part A (hospital insurance) and Part B (medical insurance) provide coverage for prescription drugs in some situations.
Original Medicare
Original Medicare (Part A and Part B) both offer coverage for prescribed drugs.
Part A covers drugs a person gets during a Medicare-covered hospital stay.
Part B generally covers drugs a healthcare provider gives a person in an outpatient setting. It may also cover other medications, including those used with durable medical equipment (DME), such as an infusion pump.
Part C and Part D
However, Medicare coverage for epinephrine auto-injectors such as EpiPen will generally be from Medicare Part C or Part D.
Part C plans, also known as Medicare Advantage, are offered by private companies and may include prescription drug coverage.
Part D plans are also offered by private companies and provide prescription drug coverage.
Medicare Advantage plans with prescription coverage and Part D drug plans each offer a list of covered drugs, also known as formularies. The formularies typically assign covered drugs to tiers, and costs are generally more for drugs in higher tiers.
A person can use this online tool to find Part D plans in their area.
The cost of an EpiPen varies, depending on a person’s healthcare coverage.
Retail cost, without coverage
In 2020, the average United States retail price for a two-pack of EpiPen is $669.82, which is the amount a person might pay without Medicare or other prescription drug coverage. A coupon might lower the cost.
The average U.S. retail price of a two-pack generic epinephrine EpiPen in 2020 was $396.41.
Cost with Medicare coverage
Costs for a person enrolled in Medicare Advantage or Medicare Part D varies depending on their plan.
Advantage plan
Many Medicare Advantage plans offer drug coverage. According to the Kaiser Family Foundation (KFF), the average deductible in 2019 was $121. Costs also depend on a person’s Advantage plan, and in which tier the drug is assigned.
Part D
A person enrolled in Part D pays a monthly premium based on their income as shown on their IRS tax return. Generally, if the reported income amount is more than $87,000, there may be income-related monthly adjustments payable in addition to the regular monthly premium. The basic Part D premium for 2021 is $33.06.
There may also be a deductible and coinsurance, depending on a person’s plan, and in which tier the drug is assigned.
In addition, costs may depend on the drug store a person uses, and whether it is out of a plan’s network, or offers standard or preferred cost sharing. The cost may also be different if a person gets mail order prescription drugs.
Assistance with EpiPen costs ranges from savings cards to Medigap plans, as well as low-income plans known as Extra Help.
Mylan savings cards
Mylan owns the EpiPen brand, and offers savings cards that can help save money on the cost of a two-pack refill, and its generic epinephrine injector. However, neither card is available to a person enrolled in Medicare.
A Mylan assistance program helps people pay for EpiPen if their income falls below a certain level. The program is not available to people with Medicare Part D.
Medigap
A person enrolled in original Medicare may also join a Medigap plan, which is supplemental insurance. The plan may help cover out-of-pocket expenses such as deductibles, copays, and coinsurance.
Prior to 2016, some Medigap policies included drug coverage. However, a person cannot enroll in both a Medigap plan and in a Part D drug prescription plan.
This online tool can help a person find a Medigap plan.
Learn more about Medigap here.
Low-income subsidy plan
Depending on a person’s amount of income and assets, they may be eligible for help with Plan D premiums through a low-income subsidy (LIS) program, also known as Extra Help.
A person at risk of a severe allergic reaction may use epinephrine auto-injectors such as EpiPen. Medicare offers some coverage for the medication and the devices, and other cost savings plans may be available.