Medicare's coverage of Dupixent depends on which part of Medicare you have and what condition you're treating

Dupixent (dupilumab) is a biologic medication used to treat moderate to severe eczema, asthma, chronic rhinosinusitis with nasal polyps, and prurigo nodularis. Medicare Part B covers Dupixent when prescribed by your doctor for an approved condition, but you will pay a share of the cost through your deductible and coinsurance. If you have Medicare Part D (prescription drug coverage) through a standalone plan or a Medicare Advantage plan, your coverage and out-of-pocket costs depend on which plan you chose and whether Dupixent is on that plan's formulary — the list of covered drugs.

The key difference: Part B covers Dupixent as an injectable medication administered in a doctor's office or infusion center, while Part D covers it if you pick it up from a pharmacy to inject at home. Most people with Medicare use the at-home injection route, which means Part D coverage matters more to your actual costs.

Key Takeaways

  • Medicare Part B covers Dupixent injections given in a medical setting, and you pay 20% coinsurance after your Part B deductible.
  • Medicare Part D covers Dupixent filled at a pharmacy, but the drug must be on your plan's formulary and you pay your plan's copay or coinsurance.
  • Dupixent is typically a specialty drug, meaning it usually falls into a higher cost tier on Part D plans.
  • Your out-of-pocket cost varies widely depending on your specific Part D plan, so comparing plans during open enrollment can save you hundreds of dollars per year.
  • Manufacturer copay information programs may reduce your out-of-pocket cost even after Medicare pays its share.

How Medicare Part B covers Dupixent in a medical setting

If your doctor administers Dupixent in their office or at an infusion center, Medicare Part B pays for the drug itself and the injection service. You pay your Part B deductible (which is $240 in 2024, though this amount changes yearly) and then 20% coinsurance for the drug and administration. This means if Dupixent costs $3,000 per injection and you've already met your deductible, you would pay $600 out of pocket.

Part B coverage requires that your doctor documents the medical reason for Dupixent and that the use matches Medicare's coverage rules. Your doctor's office handles the paperwork, and they can tell you upfront whether Medicare will cover the injection in their setting. Some practices bill Part B automatically; others may ask you to arrange it yourself.

How Medicare Part D covers Dupixent from a pharmacy

Most people with Medicare who use Dupixent pick it up from a pharmacy and inject it at home. This route uses Medicare Part D, your prescription drug plan. Part D plans vary widely — some include Dupixent on their formulary at a reasonable cost tier, while others don't cover it at all or place it in a very high tier that costs hundreds per month.

When you fill Dupixent at a pharmacy, you pay your plan's copay or coinsurance for that drug tier. Dupixent is almost always classified as a specialty drug, which means it sits in Tier 4 or Tier 5 on most plans — the highest tiers. Your copay might be $150 to $500 per month depending on your plan, or you might pay a percentage of the drug's cost (coinsurance) instead of a flat copay.

Before you start Dupixent, call your Part D plan and ask: (1) Is Dupixent on your formulary? (2) What tier is it in? (3) What will your copay or coinsurance be? This conversation takes 10 minutes and tells you exactly what to expect.

Comparing Part D plans during open enrollment

If your current Part D plan charges too much for Dupixent, you can switch to a different plan during the annual open enrollment period (October 15 to December 7 each year). Plans change their formularies and cost tiers every year, so a plan that was expensive last year might be cheaper this year, or vice versa.

Use the Medicare Plan Finder tool on Medicare.gov to compare what you would pay for Dupixent under different plans in your area. Enter Dupixent as the drug, and the tool shows you the copay or coinsurance for each plan, plus the plan's monthly premium. Sometimes paying a slightly higher premium for a plan that covers Dupixent cheaply saves you money overall.

If you're in a Medicare Advantage plan (Part C), your prescription drug coverage is built in, and Dupixent may or may not be on that plan's formulary. You can also switch to a different Medicare Advantage plan or to Original Medicare plus a standalone Part D plan during open enrollment if your current coverage is too expensive.

Manufacturer copay information and other cost-reduction programs

Sanofi, the manufacturer of Dupixent, offers a copay information program that may reduce your out-of-pocket cost. If you may have access to based on income, the program can lower your copay to as little as $0 per month. You explore through the program's website or by phone, and your doctor's office can help you with the paperwork.

To use copay information, you typically need to be enrolled in Medicare Part D and have already paid a certain amount out of pocket. The program does not pay your deductible, but it can help once you've met it. Ask your pharmacy or your doctor's office for the Dupixent copay card or information program details — they usually have them on hand.

Some state Medicaid programs and charitable organizations also offer information for people who cannot afford Dupixent, though availability depends on where you live and your specific situation. Your doctor's office social worker or patient advocate can point you toward programs in your area.

Prior authorization and coverage decisions

Medicare and most Part D plans require prior authorization before they will pay for Dupixent. This means your doctor must submit paperwork showing that you have the condition Dupixent treats and that you've tried other treatments first (or that other treatments won't work for you). The insurance company reviews this paperwork and either approves or denies coverage.

Prior authorization usually takes 3 to 5 business days. Your doctor's office submits the request, and you should ask them to tell you the outcome before you try to fill the prescription. If the request is denied, your doctor can appeal or discuss alternative treatments with you.

Medicare's coverage rules for Dupixent are based on FDA approval and clinical evidence. For eczema, asthma, and the other approved conditions, Medicare generally covers Dupixent if your doctor documents that it's medically necessary. Your doctor knows these rules and can tell you whether prior authorization is likely to be approved in your case.

What happens after you reach the Part D coverage gap

Medicare Part D has a coverage gap (sometimes called the "donut hole") that kicks in after you and your plan have spent a certain amount on drugs in a year. In 2024, the gap begins after $5,850 in total drug costs. Once you're in the gap, you pay a higher percentage of the drug cost until you reach catastrophic coverage.

Dupixent's high cost means you may reach the coverage gap quickly if you use it regularly. In the gap, you pay 25% of the drug cost (this percentage is set by law). Once your out-of-pocket costs reach $8,550 in 2024, catastrophic coverage begins and Medicare pays most of the cost.

Some Part D plans offer gap coverage for specialty drugs like Dupixent, which means you pay the same copay in the gap as you do before it. If you use Dupixent year-round, choosing a plan with gap coverage can save you thousands. Check the plan details on Medicare.gov to see which plans in your area offer this benefit.

Frequently Asked Questions

Does Medicare cover Dupixent for all skin conditions?

Medicare covers Dupixent for moderate to severe eczema (atopic dermatitis) and prurigo nodularis. It also covers Dupixent for asthma and chronic rhinosinusitis with nasal polyps. If your doctor prescribes it for a different condition, Medicare may not cover it, and your doctor can tell you whether coverage is likely before you start treatment.

What if my Part D plan doesn't cover Dupixent?

If your current plan doesn't cover Dupixent or charges too much, you can switch to a different Part D plan during open enrollment (October 15 to December 7). Use Medicare.gov's Plan Finder to see which plans in your area cover Dupixent and at what cost. You can also ask your doctor whether an alternative medication covered by your plan might work for you.

Can I use both Part B and Part D for Dupixent?

No. You use either Part B (if your doctor injects it in their office) or Part D (if you pick it up from a pharmacy). Most people use Part D because home injections are more convenient. Your doctor can tell you which route is available in their practice.

Will the copay information program work with my Medicare coverage?

Yes. The Sanofi copay information program works alongside Medicare Part D. You explore separately, and if you may have access to, the program pays your copay after Medicare pays its share. You must be enrolled in Part D and have already met your deductible to use the program. Call the program directly or ask your pharmacy for details.

How much does Dupixent cost without insurance?

Dupixent's list price is approximately $3,000 per injection, though the actual price varies by pharmacy and region. With Medicare and a Part D plan, your cost is much lower — typically $150 to $500 per month depending on your plan, or $0 if you may have access to for copay information. This is why comparing Part D plans and using information programs matters so much.