My Life Depends on Using Enbrel

@phxbarb
Hi, This is a good explanation for why meds can help us have a better quality of life. I could feel my hands, wrists and neck too! I am on Medicare so there's no Enbrel , or any injectable, in my future. But they will cover the medications given in a medical infusion center. I have come to see the week or two weeks before my appointment as time I will be coping with the chronic pain and fatigue of RA.
I hope your sinuses have healed and you don't have to go off of Enbrel anytime soon. It is not an exaggeration to say your "life depends on Enbrel."

@jw9 I am on Medicare too and Enbrel is covered for me. So you have to get an infusion ? I thought all Medicare was the same rules and laws but guess I am wrong. I actually got Enbrel free from the Amgen Foundation due to low income. This lasted for 2 years but now I am on my own with my Advantage insurance. United Health Care says it will be $35 a month, which should cover 3 injections. I am ok with that.

@phxbarb
Thank you for taking the time to reply. Wow, I have to have a talk with my rheumatologist in January! It might be different state-by-state? But that doesn't make sense because we all know Medicare is a federal program. Unless states have payments that supplement.... I intend to get some answers. I have a friend who was covered under her husband's plan when we were both in our 30's. She got Humira injections, at the time I didn't have treatment. She went into remission and by 45 started a second career. It can't hurt for me to find out if something else is available but infusion therapy. I really appreciate your post!

My wife has to go back on biologics after an upcoming heart procedure but we just saw a newly approved device from Setpoint Medical. It attaches to the Vegas nerve behind the neck and sends out an electrical signal once a day. The randomized trial showed at least a 20% decrease in joint inflammation. I saw that Northshore hospital was part of the initial trials while the list of other hospitals involved, at the moment, seem to be a secret.

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?

@becsbuddy No, I have Medicare Advantage which covers drugs.