Is Dupixent covered by Medicare?

In this article:

• How much does Dupixent cost without insurance?
• Does Medicare cover Dupixent?
• Cost of Dupixent with Medicare
• How to save on Dupixent

In this article

• How much does Dupixent cost without insurance?
• Does Medicare cover Dupixent?
• Cost of Dupixent with Medicare
• How to save on Dupixent

Dupixent (dupilumab) is a brand-name medication that has been approved by the Food and Drug Administration (FDA) to treat the following conditions:

• Moderate-to-severe atopic dermatitis (the most common type of eczema) in adults and children 6 months and older
• Moderate to severe eosinophilic asthma or asthma that is dependent on oral steroid medications in adults and children 6 years and older 
• Chronic rhinosinusitis with nasal polyps in adults 18 years and older
• Prurigo nodularis in adults 18 years and older
• Eosinophilic esophagitis (EoE) in adults and children 1 year and older

Dupixent works by stopping the action of substances in the body that cause inflammation. 

“Dupixent is considered a biologic medication, which means that it is designed to target very specific molecules within a certain pathway,”  said Gina Coscia, MD, attending physician in the Division of Allergy/Immunology at Northwell Health Physician Partners in Great Neck, New York. “Dupixent targets one part of the allergic inflammatory pathway and dampens that allergic response. It is a very specific but expensive therapy.”

With the cost of Dupixent averaging $5,000 per month, people rely on prescription drug coverage to make the drug affordable. Thankfully, Medicare Part D plans are likely to cover Dupixent, but coverage ultimately depends on the details of the plan. 

How much does Dupixent cost without insurance?

If your healthcare provider prescribes Dupixent, what you will pay depends on a variety of factors, such as whether you have insurance. And if you’re paying out of pocket, without insurance, the price you pay also depends on the pharmacy that fills your prescription. The price for the same drug can vary greatly between pharmacies, even in the same city. At the time this article was written, the average retail price of Dupixent was $5,149.24 for a month’s supply, which is two 2-milliliter prefilled syringes. 

Does Medicare cover Dupixent?

Each Medicare Part D plan has its own list of approved prescription medications. This list is known as a formulary. “A person must have one or more of certain conditions in order for Medicare to cover Dupixent,” Dr. Coscia said. “It is generally reserved for patients who have what is considered uncontrolled moderate to severe disease.” In other words, it must be considered medically necessary.

Even if your insurance covers Dupixent, your insurance provider may require your healthcare provider to submit additional medical information, such as other treatments you have tried—a process known as step therapy. Or prior authorization may be required.

Is Dupixent covered by Medicare Part B?

Prescription drug coverage through Medicare can be a little confusing. In a very general sense, Medicare A and B cover doctor’s visits and hospital stays. Medicare Part B also covers a limited number of prescription drugs, but these covered drugs are generally ones that you would not typically give to yourself, such as infusions that you get in a doctor’s office, flu shots, and vaccines. Dupixent is not covered under Medicare Part B.

Is Dupixent covered by Medicare Part D?

Medicare Part D plans will cover Dupixent if it is prescribed for an FDA-approved indication. Keep in mind, however, that Medicare Part D plans vary, just like commercial health insurance plans. So, your coverage may be different from someone else’s. Coverage also depends on the phase of Medicare coverage you’re in. “In the first phase, you pay your co-pay, and the insurance company pays the rest of the cost. Gradually, as you pay more for the drug, you start to enter what is called the donut hole,” explained Selly Vazquez, founder of SV Insurance Company and an associate of Medicare Resource Group in Brookfield, Connecticut.  

This “donut hole” is a coverage gap in most Medicare drug plans. You enter it after you and your plan have spent a certain amount on your prescription drugs. In 2024, this amount is $5,030. Once you and your plan have spent $5,030 on covered drugs in 2024, your Medicare coverage for Dupixent will change, and you’ll have to pay more for your medication (typically no more than 25% of the cost of a brand-name drug) until your total out-of-pocket spending reaches $8,000, at which point you enter catastrophic coverage and will have no further costs for covered drugs for the remainder of the year. 

Cost of Dupixent with Medicare

Your monthly cost for Dupixent can vary quite a bit. According to the manufacturers of Dupixent, around 79% of people with Medicare Part D can expect to pay $100 or less per month for Dupixent, and 21% of people with Medicare Part D may pay more than $100 per month. 

Your monthly cost for your prescription drugs can change during the year. For instance, you might pay more at the beginning of the year or more later in the year, depending on which phase of the Part D plan you are in. Whether you have met your deductible and whether your insurance provider considers the medication to be preferred or not preferred are other factors affecting how much you will pay. The cost you will pay is also impacted by whether you qualify for and enroll in Extra Help, a federal low-income subsidy that helps lower Part D costs.

Assuming Dupixent is on your Medicare Part D formulary—a list of prescription drugs it covers—there may be policies your doctor and you must follow before the drug is approved. For example, your Medicare Part D plan administrator may require your healthcare provider to prove that the drug is medically necessary through a process called prior authorization. They may also require step therapy, which involves trying other less expensive medications before Dupixent.

How to save on Dupixent

You may be able to make Dupixent more affordable with the SingleCare prescription discount card. It’s free to use, and it provides access to Dupixent coupons at more than 35,000 participating pharmacies around the country. With a SingleCare discount, you could pay $3,603 for a month’s supply instead of $5,149.

If you have Medicare Part D coverage but can’t afford your prescriptions, you can apply for the Social Security Administration’s Medicare Extra Help program. Medicare beneficiaries can apply for Extra Help anytime for help with costs like deductibles, premiums, and copays for prescription drugs, even if they’ve already enrolled in a Medicare Part D plan.

There are other ways to save on Dupixent as well, including the Dupixent MyWay copay card and the Dupixent MyWay patient assistance program. Call DUPIXENT MyWay at 844-DUPIXENT (844-387-4936) to see if you meet the eligibility requirements.