Does Medicaid cover Humira?

In this article:

• How much does Humira cost?
• Does Medicaid cover Humira?
• Factors influencing Medicaid coverage for Humira
• How to get Humira with Medicaid
• Cost of Humira with Medicaid
• How to afford Humira without Medicaid

In this article

• How much does Humira cost?
• Does Medicaid cover Humira?
• Factors influencing Medicaid coverage for Humira
• How to get Humira with Medicaid
• Cost of Humira with Medicaid
• How to afford Humira without Medicaid

Humira (adalimumab) is a brand-name prescription medication commonly used to treat autoimmune conditions such as rheumatoid arthritis, psoriatic arthritis, Crohn’s disease, and ulcerative colitis. It contains adalimumab, a tumor necrosis factor (TNF) blocker. It works by blocking TNF, a substance in the body that triggers inflammation in autoimmune diseases. Humira is a self-injection given under the skin, similar to insulin shots. It comes in a prefilled syringe or an automatic “pen” injector. 

The cost of Humira can vary depending on your insurance, the reason you need it, and the pharmacy you use. And if you have Medicaid, it may entirely or partially cover the cost of Humira.

How much does Humira cost?

Humira costs an average of $9,048 for a box of two pen injectors, which is a one-month supply. However, most people don’t pay this price, as this is the cost without insurance and discounts. There are various factors that determine how much you’ll pay for Humira, including your choice of pharmacy and the dosage prescribed to you. For example, a higher dosage or more frequent dosing schedule will increase the overall cost.

Does Medicaid cover Humira?

Medicaid coverage for Humira varies significantly from state to state. While some states may cover the medication for all approved uses, others might have stricter guidelines or require additional documentation to justify medical necessity.

It’s essential to check with your healthcare provider and state Medicaid office to determine whether it covers Humira. They can provide specific information on coverage to give you an idea of how much you can expect to pay out of pocket.

Here are a few examples:

• California Medicaid (Medi-Cal): This could require prior authorization and proof that other medications were tried first (step therapy).
• New York Medicaid: Coverage may be available but with specific requirements based on medical necessity.

Factors influencing Medicaid coverage for Humira

If Medicaid covers Humira in your state, several factors could influence your eligibility for coverage. These factors might include:

• Your diagnosis: You may need a specific diagnosis, such as rheumatoid arthritis or Crohn’s disease, that aligns with the state’s coverage criteria.
• Your treatment history: Before Medicaid covers Humira, you may be required to show that other less expensive treatments are ineffective. This is often referred to as step therapy.
• Prior authorization: Your state Medicaid agency may require your healthcare provider to submit documentation proving that Humira is medically necessary for your condition.

These criteria can vary widely from state to state, so it’s important to consult your healthcare provider and your state’s Medicaid office to understand what to expect when using Medicaid to pay for Humira.

How to get Humira with Medicaid

If you are eligible for Medicaid coverage for Humira, follow these steps to obtain the medication:

1. Discuss your condition with your healthcare provider to determine if Humira is the right treatment option. If they believe it is your best option, they’ll write you a prescription.
2. Your healthcare provider must submit a prior authorization request to Medicaid, which requires providing your medical history and an explanation of why you need Humira. This could be time-consuming, so be sure to discuss interim treatment options to help manage your symptoms until you can get your prescription filled.
3. Once the prior authorization is approved, take your prescription to a pharmacy that accepts Medicaid. If there are any issues, your pharmacist may contact your healthcare provider or Medicaid office.

Cost of Humira with Medicaid

AbbVie Inc., the manufacturer of Humira, says most people with Medicaid coverage for Humira pay less than $20 each month, although coverage varies by state. Medicaid can reduce the cost significantly, but you may still need to cover some out-of-pocket expenses, such as:

• Copayments: Some states may require you to pay a small fee, typically between $0 and $10, each time you fill your Humira prescription. 
• Coinsurance: Depending on your state of residence, you might need to pay a percentage of the medication’s cost.
• Monthly premiums: If you must pay a premium for your Medicaid coverage, this could also factor into your overall cost.
• Deductible: Your plan may require you to pay a certain amount before coverage begins. 

To better understand what you might pay, check your state’s Medicaid preferred drug list or contact your Medicaid office.

How to afford Humira without Medicaid

If you do not have Medicaid or your state does not cover Humira, there are several ways to reduce the cost, including:

• Using a SingleCare prescription discount card: SingleCare provides instant access to coupons you can use at pharmacies around the country. With a SingleCare coupon for Humira, you could pay $5,975 instead of the average retail price, which is $9,048 at the time of publication.
• Considering Humira alternatives: Humira is not available as a generic drug because it is a biologic medication made from living cells. However, biosimilar versions are available. These biosimilar alternatives are approved by the Food and Drug Administration and offer a lower-cost option while maintaining the same safety and effectiveness.

RELATED: Humira patient assistance

To understand how much you need to pay for Humira with Medicaid, it’s essential to know how your state Medicaid agency covers it. Without coverage, there are ways to get discounts and programs that can make Humira more affordable. Remember that, if you have both Medicare and Medicaid, you are considered dually eligible, meaning you can use Medicaid to pay for certain things that Medicare won’t.