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Does Blue Cross cover Humira?

For specific copays and coinsurance, it’s best to check with your specific BCBS health insurance plan
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By | Oct. 9, 2024 Medically reviewed by Josephine Bawab, Pharm.D.
A health insurance card with a stethoscope and medication: Does Blue Cross cover Humira?

Key takeaways

  • Humira is a prescription medication in a class of drugs called TNF blockers, used primarily to treat rheumatoid arthritis, Crohn’s disease, plaque psoriasis, and other inflammatory health conditions.

  • Many Blue Cross Blue Shield plans will cover Humira, but it depends on the specific plan, prescription, and BCBS company.

  • Because it’s a specialty drug, Humira often falls into the higher tiers on a prescription drug plan’s formulary, so it might have higher copays than other drugs.

  • To check a plan’s specific coverage details, look up Humira on its formulary (drug list).

In this article:

Humira (adalimumab) is a TNF blocker, an immunosuppressant drug that can treat the symptoms of rheumatoid arthritis, Crohn’s disease, and psoriatic arthritis, along with other inflammatory diseases like ankylosing spondylitis and plaque psoriasis. However, its effectiveness and versatility come at a cost, which leaves many people looking to their insurance provider for help.

Many health insurance and Medicare Part D plans will cover Humira, including some from Blue Cross Blue Shield, but it depends on the specific plan. Here’s what you need to know.

Does Blue Cross Blue Shield cover Humira?

Yes, some Blue Cross Blue Shield (BCBS) plans cover Humira, but that doesn’t mean everyone will get coverage. BCBS has a range of plans, and they all have different prescription drug benefits.

The Blue Cross and Blue Shield Association isn’t a single company either. Rather, it’s various independent and locally operated companies and licensees. If you live in New York, your BCBS plan’s policies could vary significantly from a BCBS beneficiary living in Florida, Texas, or anywhere else.

Many of these plans will cover Humira if it’s essential for your condition, but there may be some caveats. “Since it’s considered a specialty drug, you may need prior authorization or have to go through step therapy before getting approval,” says Andrew Youssouf, MD, medical director of Ikon Recovery. Prior authorization is the process by which insurance companies confirm a drug is medically necessary—typically involving some extra paperwork on your healthcare provider’s end. Step therapy means trying other, less expensive drugs before you can qualify for coverage. As a specialty medication, Humira requires specific handling, administration, and monitoring, so you have to get it from a specialty pharmacy or other designated location.

If you have a Medicare Part D or Medicare Advantage plan, it works pretty much the same way. For people who receive their Humira injections in their healthcare provider’s office, however, it might fall under Medicare Part B instead.

RELATED: Does Medicaid cover Humira?

What about Humira biosimilars?

Humira is a biologic drug, which means it’s created from living cells rather than synthetic chemicals. This is an expensive and time-consuming process, which is why biologics often cost more than other drugs. Fortunately, the Food and Drug Administration (FDA) has approved several Humira biosimilars, including Amjevita, Cyltezo, Hadlima, and Yuflyma.

Biosimilar drugs are almost identical to their brand-name biologic counterparts, and the FDA says that they’re “just as safe and effective as their reference products.” Like generic drugs, they’re also often less expensive. However, many of them are pretty new, and some BCBS plans don’t cover them as consistently as Humira. Still, it may be worth checking their prices.

RELATED: Humira generic availability, cost, and dosage

How much does Humira cost?

For many people, insurance coverage is important, since Humira’s average out-of-pocket cost without it is around $9,283 for two autoinjectors—typically a one-month supply. At that price, an annual supply would cost more than $100,000. Fortunately, many people either find insurance coverage or take advantage of other ways to save on Humira, which we’ll cover later.

Even when it’s included in your medical benefits, health insurance plans have cost-sharing policies where the beneficiary must pay certain portions of the price. The most common way they do this is through copays. Many plans organize drugs into tiers, covering more for lower tiers than higher ones. “Each plan is different, but Humira is usually on the higher end of the drug list,” Dr. Youssouf says. “Which means you might have to pay more in copays or coinsurance,” he adds.

Data from KFF shows that the average copayment is $11 for tier 1 drugs, $36 for tier 2 drugs, $66 for tier 3 drugs, and $125 for tier 4 drugs. But, Humira can sometimes have a much higher copay because of its high price and specialty classification.

How much does Humira cost with Blue Cross Blue Shield?

It could be $0, or it could be a lot more. Once again, it depends on your plan. Beyond copays, BCBS and other insurance companies have a few other ways to dictate the beneficiary’s out-of-pocket costs. One is your deductible, which is the total amount you need to pay before coverage kicks in. After you hit your deductible, the insurance provider may cover all of your prescription drug costs, or they may only cover a certain percentage (coinsurance). A drug’s tier usually dictates the plan’s copay and coinsurance amounts.

How to check whether your Blue Cross Blue Shield plan covers Humira 

Whether it’s copays, coinsurance, deductibles, or drug tiers, the hub for all this prescription drug coverage information is your plan’s formulary. This is a drug list that shows each medication’s tier and other requirements, like prior authorization.

The independent licensees of the Blue Cross usually house drug lists for each of their plans online. One fairly easy way to find them is to search for “Blue Cross Blue Shield drug lists” plus the name of your state. Once you’re viewing the formulary, scroll down until you find Humira. It should list its tier and whether there are any prior authorization requirements or other restrictions. “It’s also a good idea to review your Summary of Benefits and Coverage document to fully grasp the expenses,” Dr. Youssouf says. “Depending on your plan, using a specialty pharmacy may be required and could potentially have lower costs through certain networks.”

You also have the option of calling your state’s Blue Cross Blue Shield company directly and speaking with a representative. They’ll likely ask for your group number and member ID, so have your insurance card ready.

How to save on Humira

Insurance can significantly decrease your prescription medication costs, but it’s not the only way to do so. Patient assistance programs from the manufacturer, government assistance programs, and asking a healthcare provider about biosimilar options are all ways to save money on Humira.

Plus, Humira coupons from SingleCare can help take thousands of dollars off the average price. SingleCare works directly with partnering pharmacies and pharmacists to secure discounts on thousands of drugs, and anyone can sign up to get them. You can use these coupons even if you have a BCBS insurance plan, but you can’t use the discounts and insurance coverage simultaneously. So, take a look at your formulary and determine which option might give you the biggest savings.

RELATED: Humira alternatives

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