Does Aetna cover Dupixent?

In this article:

• Does Aetna cover Dupixent?
• How much does Dupixent cost?
• How to check whether your Aetna plan covers Dupixent 
• How to save on Dupixent

In this article

• Does Aetna cover Dupixent?
• How much does Dupixent cost?
• How to check whether your Aetna plan covers Dupixent 
• How to save on Dupixent

Dupixent (dupilumab) is a prescription brand-name drug that can be prescribed for various health conditions, including atopic dermatitis (a type of eczema), asthma, eosinophilic esophagitis (EOE), prurigo nodularis, and chronic rhinosinusitis with nasal polyps (CRSwNP). The Food and Drug Administration (FDA) has recently approved it for treating inadequately controlled chronic obstructive pulmonary disease (COPD) as well. 

As a relatively new biologic drug that treats so many conditions, Dupixent can be expensive—especially since there’s no biosimilar (generic) alternative. If you have health insurance from Aetna, you might be wondering if your prescription drug benefits cover Dupixent. Although Aetna does cover Dupixent in certain cases, the amount of coverage it offers depends on your specific plan and circumstances. Here are all the important details about how Aetna covers biologic drugs like Dupixent.

Does Aetna cover Dupixent?

Usually, yes, Aetna plans will cover Dupixent for people with atopic dermatitis. Regeneron and Sanofi, the developers of Dupixent, claim that 99% of commercially insured individuals receive some type of coverage for Dupixent (often after other medications have not been effective). But the real question isn’t necessarily whether your plan will cover Dupixent—it’s how much it will cover. And there are a few variables that may determine your level of coverage.

Drug tier

Like most health insurance providers, Aetna organizes its covered drugs by tier in its drug formularies. These formularies vary by plan somewhat, but tier 1 is typically reserved for generic drugs, while brand-name, nonpreferred, and specialty drugs occupy the higher tiers. 

Insurance plans typically have different cost-sharing policies for each tier. The higher the tier, the higher the patient copay. Because it’s a specialty drug, Dupixent occupies at least tier 2 in most plans, but it varies. The only way to know for sure is to check your plan’s formulary.

Prior authorization

Even when Dupixent is covered, it’s not always as simple as walking into a pharmacy and getting your prescription. “Prior authorizations are needed, due to the cost of the meds,” says Navin Arora, DO, FAAD, founder of Borealis Dermatology. This is how the company determines Dupixent is medically necessary before issuing coverage. It might be as simple as your healthcare provider sending some extra paperwork, but it could be as involved as trying other, less expensive alternatives first—which is called step therapy. However, despite Dupixent’s common prior authorization requirements, Dr. Arora says it ends up being covered most of the time.

Reason for prescription

Most often, health insurance providers will only cover drugs for the conditions the FDA has approved them for. Some recent studies have suggested Dupixent can treat other skin or allergic conditions, but insurance companies might not help pay for those off-label (non-FDA-approved) uses. Instead, they’re more likely to cover Dupixent for its FDA-approved uses: moderate-to-severe atopic dermatitis, asthma, prurigo nodularis, EOE, CRSwNP, and COPD. 

How much does Dupixent cost?

The cost of Dupixent without insurance varies by pharmacy and location, but it averages $5,226 for 2, 2 mL prefilled syringes. That’s for one month of treatment on average, depending on the age, reason for use, and dosage—some patients will only need one syringe per month, while others need up to four.

According to Sanofi and Regeneron, 60% of people with employer-sponsored plans pay between $0 and $100 in copays per month for Dupixent, and the other 40% pay over $100. For people with a Medicare Part D plan, 79% pay $0–$100, while the remaining 21% pay over $100.

RELATED: Is Dupixent covered by Medicare?

How to check whether your Aetna plan covers Dupixent 

We mentioned formularies—or covered drug lists—earlier, and those are the go-to guides for determining drug coverage. The easiest way to search your Aetna formulary is by logging into your member portal on Aetna.com. From there, click on the “Prescriptions” tab, and you can search for Dupixent. The site will show you how much your plan will cover and how much you’ll need to pay out of pocket.

Aetna’s website also has a page where you can search for drugs under any plan, and it will show you the average out-of-pocket costs and copays. Of course, if you’d rather talk to a person, you can always call Aetna. Just have your insurance card on hand, because the representative will need to confirm your member ID, group number, and other information.

How to save on Dupixent

Insurance is perhaps the most common way to save on Dupixent, but it’s far from the only one. For example, a free SingleCare prescription discount card provides access to coupons you can use at participating pharmacies across the country. With a SingleCare coupon for Dupixent, you could pay $3,605 instead of $5,226 for 2, 2 mL pens.  

Beyond that, “the Dupixent MyWay Copay Card may help eligible patients cover the out-of-pocket cost of Dupixent,” Dr. Arora says. “It is essentially a subsidized program by the manufacturer. However, approval is not guaranteed.” There are also government programs and other strategies you can use to save money on Dupixent—with or without insurance.

You could also ask your healthcare provider about Dupixent alternatives. Not all of them will be less expensive, but some might receive better coverage from certain Aetna plans.