Does Medicare cover Enbrel?

In this article:

• How much does Enbrel cost?
• Is Enbrel covered by Medicare?
• How much does Enbrel cost on Medicare?
• How to save on Enbrel

In this article

• How much does Enbrel cost?
• Is Enbrel covered by Medicare?
• How much does Enbrel cost on Medicare?
• How to save on Enbrel

Enbrel (etanercept) is a medication that is prescribed to treat rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and plaque psoriasis. Enbrel is also approved by the Food and Drug Administration (FDA) to treat polyarticular juvenile idiopathic arthritis (JIA) in patients ages two and older.

“As an adult rheumatologist, I prescribe Enbrel for rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis,” says Emily Carroll, MD, assistant professor of medicine in the Division of Rheumatology at the Icahn School of Medicine at Mount Sinai Medical Center in New York City. “Dermatologists and pediatric rheumatologists prescribe it for other conditions.”

Enbrel is a tumor necrosis factor (TNF) inhibitor. TNF is a protein in your body that causes inflammation, and TNF inhibitors like Enbrel work to stop that inflammation. Enbrel is one of several TNF inhibitors approved by the FDA. 

Healthcare providers don’t typically prescribe Enbrel for very young children, according to Dr. Carroll, and there is no absolute upper age limit. “But in an older population, we are cautious with this drug and any immunosuppressive therapies due to the risk of infection. Older people may be more at risk for infection,” Dr. Carrol says.

“The standard dose is 50 milligrams (mg) once per week via an injection under the skin. Children may be prescribed lower doses based on their weight,” says Jason Liebowitz, MD, assistant professor of medicine at Columbia Vagelos College of Physicians and Surgeons in New York City.  People with moderate to severe plaque psoriasis may be prescribed two 50 mg doses per week for the first three months, followed by one 50 mg dose weekly after that. 

How much does Enbrel cost?

A person without health insurance would pay an average of $8,500 a month for a 28-day supply of four 50 mg Enbrel Mini autoinjectors, Enbrel AutoTouch autoinjectors, or prefilled syringes. The list price, the price at which the manufacturer sells its drugs to wholesalers, is $1850.46 per weekly 50 mg dose, although most people don’t pay the list price. Your cost will vary based on your health insurance coverage and the dosage your healthcare provider prescribes. If you have Medicare prescription drug coverage, the actual out-of-pocket cost for Enbrel may be less.

Why is Enbrel so expensive? It is a specialty drug that’s also a biologic, which “are much more complex to develop and produce than regular drugs, which factors into their cost,” Dr. Carroll explains. “Amgen, the pharmaceutical company that produces Enbrel in the United States, still has patent protection over the drug, meaning other companies cannot yet make ‘biosimilar’ versions of the medication that tend to be less expensive.” There is no Enbrel biosimilar (comparable to a generic) yet. 

Is Enbrel covered by Medicare?

Enbrel is covered by most Medicare Part D and Part C (Medicare Advantage) plans. The price Medicare beneficiaries pay for this drug depends on a variety of factors.

“It depends on which Medicare prescription drug plan you have,” Dr. Carroll says. “The vast majority of Medicare plans do cover Enbrel, assuming there is a medical necessity for the drug.”

When you have Medicare Part A and Part B, you may choose to join a Medicare Advantage Plan (Medicare Part C), which typically includes drug coverage. These plans are administered through private insurance companies, and they are approved and regulated by Medicare. The insurance company decides if a particular plan will be available to everyone with Medicare in your state or only in certain counties. They can offer more than one plan in an area, each with different costs and benefits.

If you have a Medicare Advantage plan, prescription coverage is usually built in, explains Selly Vazquez, founder of SV Insurance Company and an Associate of Medicare Resource Group in Brookfield, Connecticut. 

If you have an Original Medicare (with or without a supplemental Medigap plan), instead of a Medicare Advantage plan, you may choose to enroll in a standalone prescription drug plan through Medicare Part D.

No matter what type of prescription drug coverage you have, there is a list of covered drugs arranged in a tiered format that is known as a “formulary.” Formularies differ depending on the prescription drug plan, but in each case, drugs are assigned certain levels, called “tiers,” on their formularies. “Drugs in the lower tiers cost less than drugs in higher tiers,” Vazquez explains. Prescription plans can change what tier a particular drug is assigned to at any time.

“Besides being on your plan’s formulary, Enbrel must be prescribed for an approved indication,” Dr. Carroll says. Approved indications include, for instance, plaque psoriasis, rheumatoid arthritis, ankylosing spondylitis, and juvenile rheumatoid arthritis. “But if someone were hoping to get Enbrel approved for an indication where it has no proven role, like osteoarthritis, then Medicare may not cover it,” Dr. Carroll explains.

Even if Enbrel is covered by your Medicare prescription drug plan, there is no guarantee that it will automatically be covered for you. “Some insurance may require step therapy, which means the patient must try and fail one or more other medications first,” Dr. Liebowitz says. They may also require prior authorization or enforce quantity limits. There are other TNF inhibitors, and your plan may cover one of these but not cover Enbrel.

How much does Enbrel cost on Medicare?

“The cost really varies,” Vazquez says. In order to understand how prescription drug coverage works with Medicare, it’s key to understand the four stages of Medicare prescription drug coverage.

The first is the deductible stage. In the deductible phase, the beneficiary pays for 100% of drug costs for drugs on all tiers. 

In the second, the initial coverage stage, you and the pharmacy both pay toward a prescription. “The patient only pays a minimal portion in the form of a copayment, and the insurance company usually pays the bigger portion,” Vazquez explains. 

After your total drug costs during the initial coverage period reach a certain limit, you’ll enter the third stage, which is known as the coverage gap, or the donut hole. In 2024, that limit is $5,030. “The member now pays 25% of the retail cost of the prescription,” Vazquez says. “Once the member has paid $8,000 in total annual drug costs, which is up $600 from 2023, then you enter the last stage of the prescription drug plan.” 

In the fourth, or catastrophic coverage stage, “your Medicare prescription drug plan absorbs the full cost of the drug until the end of the year,” Vazquez says.

How to save on Enbrel

You may save money on Enbrel by using a SingleCare Prescription Discount Card. Although Part D beneficiaries may not combine these savings with their Medicare Part D plans, in some instances, these coupons may offer more savings. This is because every Part D plan has a different formulary. While the average monthly retail price of Enbrel is $8,465.27 for four 50 mg syringes, you may pay only $6,507.50 at participating pharmacies with a SingleCare Enbrel coupon.

If you have Medicare and meet certain criteria, you may be eligible for extra help paying for prescriptions through Medicare Part D Extra Help. If you qualify, you could pay $11.20 or less for Enbrel. Also, Medicare Extra Help Beneficiaries don’t have to enter the coverage gap (donut hole) where they’d otherwise be responsible for paying a portion of their drug costs. You may also want to check whether your state has a pharmaceutical assistance program.

You could also look to the manufacturer, Amgen Inc., for savings. Enbrel offers financial support resources along with other patient support services, including a copay card that offers significant savings.