This is from AI. The short version is to make sure you pick a part D plan or advantage plan that lists enbrel on its formulary. This is easy to do on Medicare.com website. Also remember that with part D, medication costs are capped at $2000 per year.
Yes, Enbrel is often covered by Medicare, but only through certain types of plans and under specific conditions.[singlecare +2]
How Medicare Can Cover Enbrel
• Original Medicare (Parts A and B) by itself does not cover self-injected drugs like Enbrel; you generally need prescription drug coverage through either a standalone Part D plan or a Medicare Advantage plan that includes drug coverage.[oakstreethealth +1]
• Many Part D and Medicare Advantage plans do list Enbrel on their formularies, but coverage, prior authorization requirements, and out-of-pocket costs vary by plan and location.[medicalnewstoday +2]
Typical Requirements and Costs
• Plans usually require that Enbrel be prescribed for an FDA‑approved indication such as rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, or plaque psoriasis, and may require step therapy or prior authorization.[healthline +1]
• Enbrel is treated as a “specialty” drug, so coinsurance or copays can be high, but starting in 2025, annual Part D out‑of‑pocket spending on covered drugs is capped (around $2,000), after which the plan pays the rest for that year.[medicalnewstoday]
Help With Costs
• Some people qualify for Medicare’s Extra Help program or state pharmaceutical assistance programs, which can greatly reduce copays for Part D drugs like Enbrel.[singlecare +1]
• The manufacturer (Amgen) also offers financial support resources, though some copay programs may not apply to people with government insurance, so eligibility details matter.[enbrelpro +2]
What You Should Do Next
• Check your plan’s formulary (or use the Medicare Plan Finder) to see if Enbrel is listed, what tier it is, and what your expected copay or coinsurance would be.
• Ask your prescriber’s office and your specialty pharmacy to help with prior authorization and to screen you for Extra Help or manufacturer assistance based on your income and resources
@laura1970 So, did you sign up for Medicare part D?