- Humira is biologic drug that’s used to treat inflammatory conditions like rheumatoid arthritis, plaque psoriasis, and Crohn’s disease.
- Humira is mainly covered by Medicare Part D and Part C; in rare cases, Part B may also offer coverage.
- Since Humira is considered a specialty drug, it can be expensive, though many factors play into the cost you’ll pay.
- You may be able to get help paying for the cost of Humira in several ways.
Humira is a type of biologic medication. It can be used to treat a variety of health conditions, such as rheumatoid arthritis and plaque psoriasis. Many of these conditions are chronic in nature, which means they need continued treatment for lifelong management.
Medicare covers Humira. In fact, it’s estimated that
Keep reading to learn more about Humira, what parts of Medicare cover it, and how much it may cost you.
Medicare does provide coverage for Humira. It’s usually covered through Medicare Part D, which is Medicare’s prescription drug coverage.
Companies that sell Part D plans will have a formulary. This is a list of all the prescription drugs the plan covers.
Formularies often include at least two medications for each drug class. If you take Humira, you can find out which plans cover it by comparing different Part D plans.
Additionally, the formulary often divides the covered prescription drugs into different tiers. Those listed in higher tiers (tiers 3 to 5) typically cost more than those in lower tiers (tiers 1 and 2).
Medicare Part B may cover Humira if a doctor administers the medication in an outpatient setting. However, since Humira is now often self-administered at home, it’s less likely that Part B will cover it.
What if I have Medicare Advantage?
The cost of a Part C plan can vary based on your location.
Part D prescription drug coverage is included in most Part C plans. If you want prescription drug coverage with your Part C plan, you’ll have to include that coverage when you shop for a plan.
You can’t enroll in a separate Part D plan if you have Medicare Advantage.
As with Part D, it’s important to review a Part C plan’s formulary to see if the medications you take are listed there. If you have additional questions or concerns, don’t hesitate to contact your pharmacy or the plan’s company directly.
Can a Medigap plan help with my costs?
Medigap is a form of supplemental insurance sold by private insurance companies. A Medigap plan can help pay for costs that original Medicare (parts A and B) doesn’t cover.
These plans can’t be used with Part C (Medicare Advantage). You must choose one or the other.
Prior to 2006, some Medigap plans offered coverage to help with prescription drug costs. However, Medigap plans are no longer permitted to offer this coverage. Though these plans have been discontinued, you can keep your plan if you’re already enrolled in one.
Since Humira is a specialty drug, it can be expensive. You may find that Humira is listed in the higher tiers of a plan’s formulary.
A 2019 study looked at the total cost of Humira by combining the amount that insurance companies paid plus the out-of-pocket costs paid by their beneficiaries. The study found that the median cost of Humira per month was
The costs of Humira under Medicare can depend on where you are in your prescription drug coverage. Let’s take a closer look the costs at each threshold of coverage:
- Deductible. Each Part D plan has a yearly deductible. For 2020, this cost cannot exceed $435 for any plan. You must pay the deductible out of pocket before your plan will begin to cover your Humira prescription.
- Coverage. Once you meet your deductible, you’ll pay a copayment or coinsurance when you fill your Humira prescription. The exact amount of this payment will depend on your specific plan.
- Donut hole. After you and your plan have spent a certain amount — $4,020 in 2020 — you enter a coverage gap. This period is referred to as the donut hole. While you’re in the donut hole, you’ll pay no more than 25 percent of the cost of a brand name prescription like Humira.
- Catastrophic coverage. In 2020, you’ll leave the donut hole once you pay a combined total $6,350 during the course of a year. In this phase, you’ll pay only a small copayment or coinsurance for your Humira prescription (as well as any other drugs you may need).
A study from early 2020 used data from formularies and pricing files to estimate the yearly out-of-pocket costs for Humira under a Part D plan. These projections indicated that Humira could cost an individual
If you’re concerned about the costs of Humira, you can get help in several ways. Let’s explore them in a little more detail below.
Medicare Extra Help
Medicare Extra Help is a program that assists people who have limited income or resources with paying for prescription drugs. With Extra Help, you pay no more than $8.95 for brand name drugs like Humira.
If you already have Medicaid, Social Security insurance, or a Medicare savings plan, you’ll automatically qualify for Extra Help. Otherwise, you can apply for Extra Help through the Social Security Administration website, as long as you meet certain income limits.
Medicaid is a federal and state program that helps pay for healthcare for those with lower incomes. While eligibility and benefits can vary by state, Medicaid programs in some states may help with the cost of prescription drugs.
You can use the Medicaid website to find information on your state’s Medicaid office.
Programs of All-Inclusive Care for the Elderly (PACE) is available through Medicare and Medicaid and can help you find care while living at home in your community, as opposed to a nursing home.
One of the benefits that may be covered by PACE is prescription drugs.
Pharmaceutical assistance programs
Pharmaceutical assistance programs are available through drug manufacturers and other foundations to help you pay for specific medications. To check on pharmaceutical assistance programs for Humira, you can use this Medicare search tool.
Additionally, some states may have their own pharmaceutical assistance programs. You can search here to see if your state has a pharmaceutical assistance program.
Pharmacy discount companies
Humira (adalimumab) belongs to a class of drug called biologics. These are genetically engineered proteins that act on the immune system.
Humira is FDA approved to treat a variety of inflammatory conditions, including:
- rheumatoid arthritis
- plaque psoriasis
- Crohn’s disease
- ulcerative colitis
- psoriatic arthritis
- juvenile idiopathic arthritis
- ankylosing spondylitis (chronic autoimmune disease that affects the joints)
- hidradenitis suppurativa (chronic inflammatory skin condition)
- uveitis (swelling of the middle layer of the eye)
Like other biologic medications, Humira works by targeting a specific part of the immune system. It binds to and inhibits a protein called tumor necrosis factor alpha (TNF-a), which is involved in the inflammatory process.
Humira is given by injection into your thigh or lower abdomen. The frequency of these injections depends on your specific condition.
Common side effects of Humira include:
- increased risk for certain infections
However, these may not yet be available, due to the patents currently associated with Humira. Talk with your doctor about all your options for medication in order to decide what will work best for you.
Medicare typically covers Humira. This coverage is often provided by Medicare Part D or Part C plans.
Each insurance company chooses the prescription drugs it covers and lists them in a formulary. Because of this, it’s important to check a specific plan’s formulary to make sure that Humira is included.
While the cost of Humira can potentially be high, numerous programs can help lower your costs. Some examples include Medicare Extra Help, Medicaid, and pharmaceutical assistance programs.