What to Know About Medicare and Enbrel Coverage

Enbrel (etanercept) is a tumor necrosis factor (TNF) blocker used to treat autoimmune diseases like rheumatoid arthritis, psoriatic arthritis, or ankylosing spondylitis. It helps prevent joint damage linked to these health conditions.

Read on below to learn more about how coverage for Enbrel works with Medicare, including how Medicare drug coverage works in general.

Enbrel (etanercept) is a tumor necrosis factor (TNF) blocker used to treat autoimmune diseases such as severe rheumatoid arthritis, psoriatic arthritis, or ankylosing spondylitis. It helps prevent joint damage linked to these conditions and since it is considered a specialty drug, there are no generic versions of it available.

Enbrel is injected under the skin. It can be injected into the abdomen, thigh, or the outer area of the upper arm. Dosage and how often Enbrel must be administered will depend on the patient’s diagnosis.

Warnings and Side Effects

Common side effects include:

• Infection (including common cold or flu)

• Injection site reaction

• Diarrhea

Enbrel also increases the risk of serious infections, some cancers, heart failure, and more. Medicare beneficiaries should always inform their medical provider of their medical history to make sure they are not more susceptible to adverse outcomes.

How Expensive is Enbrel?

Because Enbrel is a specialty medication, it is quite expensive. Without health insurance, Enbrel runs around $9,590.86.

As a reminder, Original Medicare only consists of Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). These Medicare Parts do not include coverage for prescription drugs such as Enbrel. As such, those who only have an Original Medicare plan need to enroll in a Medicare drug plan, known as Medicare Part D, in order to receive coverage for prescription drugs.

Medicare Part D is Medicare’s prescription drug coverage, working as a Medicare supplement insurance to cover prescription drug costs. Most Medicare drug plans include a monthly premium, yearly deductible, copayments, and coinsurance. Medicare drug plans’ overall costs will vary. Factors that contribute to costs include:

• Prescriptions: What prescriptions a beneficiary needs and whether they’re on the drug plan’s list of covered medications, known as the plan’s formulary can affect cost.

• Medication Tier: What tier the medication is in can affect the plan’s cost.

• Drug Benefit Phase: Which drug benefit phase the beneficiary is in can affect the plan’s cost,i.e. whether they’ve paid their deductible or if they’re in the catastrophic coverage phase.

• Pharmacy: What pharmacy type and location impacts Part D’s cost.

• Medicare Extra Help Enrollment: Whether a beneficiary is enrolled in the Medicare Extra Help program can impact their Part D cost.

Medicare enrollees are encouraged to compare Medicare prescription drug plans to find the best option for them.

Note: Learn more about Medicare Part D costs at this resource.

Does Medicare Part D Cover Enbrel?

Many Medicare Part D plans cover Enbrel. Copays range from $338 to $7003, depending on a beneficiary’s coverage stage. That said, coverage and cost will still depend on the specific plan chosen which is why it’s important to contact your health insurance company to discuss costs and coverage before making any final decisions or payments.

Quantity limits and prior authorization may apply. A quality limit is how much medication a beneficiary can fill at one time. Prior authorization is when an insurance company requires healthcare providers to seek approval from the patient’s insurance company before a medication or other healthcare service will be covered.

Enbrel is also typically a Tier 5 medication. The higher the tier, the more expensive a medication usually is. Most plans have five tiers. Tier information is provided on the plan’s formulary.

Medicare Advantage plans, also known as Medicare Part C or MA plans, may include prescription drug benefits. MA plans are a type of Medicare supplement plan and are provided by private insurance companies that are Medicare-approved. Medicare Part C plans consist of the standard Medicare coverage (Medicare Part A and Medicare Part B), in addition to other healthcare benefits including vision, hearing, and prescription drugs. Exact benefits will vary per plan. MA plan beneficiaries should confirm extra benefits with their insurance company.

Do Medicare Advantage Plans Cover Enbrel?

Many Medicare Part C plans may cover Enbrel. However, it will depend on the specific MA plan chosen since not all Medicare Advantage plans include coverage for prescription drugs. If an MA plan does include prescription drug coverage, beneficiaries can look at their plan’s formulary for a list of covered drugs to see if Enbrel is included.

Out-of-pocket costs for prescription medications can add up quickly, even with coverage. There are a number of patient assistance programs that can help Medicare beneficiaries with these drug costs, however.

Extra Help Program

The Extra Help Program is a Medicare program to help beneficiaries with limited income or resources pay for a Medicare prescription drug plan. Some people automatically will qualify for Extra Help, such as those who qualify for the QMB program, SLMB, or QI program under Medicare Savings Programs.

SHIP

The State Health Insurance Assistance Program (SHIP) is a national program that helps Medicare beneficiaries, caregivers, and family members make informed choices about their Medicare benefits and navigate all of their options.

GoodRx

GoodRx is both a website and mobile application that finds discount pricing for prescription medications.

Medicaid (Dual Eligibles)

Beneficiaries eligible for the Medicaid ​“Dual Eligibles” program will be eligible to use the Medicaid Drug Rebate Program (MDRP). This program helps to offset the Federal and state costs for prescription drugs.

PACE

PACE stands for Program of All-Inclusive Care for the Elderly. It is a Medicare and Medicaid program that provides all the care and services covered by Medicare and Medicaid if authorized by someone’s health care team. This includes prescription drugs. Those in a PACE program do not need to enroll in a separate Medicare Part D drug plan.

Medigap/​MedSupp

Medigap or MedSupp plans are supplemental Medicare plans that intend to ​“fill in the gaps” of Original Medicare. Medigap plans often help with deductible, copayment, and coinsurance payments.

When it comes to prescription drugs, someone cannot be enrolled in both a Medicare prescription drug plan as well as a have a Medigap policy with drug coverage. Learn more about Medigap and Medicare drug coverage at this resource.