Medicare's Coverage of EpiPens

Medicare Part B covers EpiPens and other epinephrine auto-injectors, but only when prescribed by a doctor and obtained through a pharmacy or medical supplier. You will pay 20% of the approved amount after you meet your Part B deductible. The exact cost depends on which pharmacy you use and whether the EpiPen is on your plan's formulary — the list of covered drugs.

If you have a Medigap or Medicare Advantage plan in addition to Original Medicare, your out-of-pocket cost may be lower. Some Medigap plans cover the 20% coinsurance, and Medicare Advantage plans set their own copays for prescription drugs. You should check your specific plan documents or call your plan to find out what you will pay.

Key Takeaways

  • Medicare Part B covers EpiPens when prescribed by a doctor, but you pay 20% of the approved cost after your deductible.
  • The actual price you pay varies by pharmacy, so calling ahead to compare costs is worth your time.
  • If you have a Medigap or Medicare Advantage plan, your copay or coinsurance may be lower than the standard 20%.
  • You need a prescription from your doctor; Medicare does not cover EpiPens bought over the counter.
  • If cost is a barrier, ask your doctor about generic epinephrine auto-injectors, which may have lower copays.

How to Get an EpiPen Through Medicare

Start by asking your doctor for a prescription. Your doctor will write it for a specific type of epinephrine auto-injector — usually a brand-name EpiPen, a generic epinephrine auto-injector, or Auvi-Q, which is another brand. Tell your doctor if cost is a concern, because generic versions are often cheaper.

Once you have the prescription, take it to a pharmacy that accepts Medicare. Call ahead and ask the pharmacist what your out-of-pocket cost will be, because prices vary significantly between pharmacies. Some pharmacies offer discount programs that may lower your cost even further. You can also ask whether a generic epinephrine auto-injector would be cheaper than the brand name your doctor prescribed.

If the cost is higher than you expected, ask the pharmacist whether your Medicare plan requires prior authorization — approval from your insurance company before the pharmacy fills the prescription. If prior authorization is needed, the pharmacy will handle the request, but it may add a few days to the process.

What Medicare Part B Actually Covers

Medicare Part B covers injectable medications like epinephrine auto-injectors when they are prescribed by a doctor and dispensed by a licensed pharmacy. This is different from medications you take by mouth, which are covered under Part D (prescription drug coverage). Because EpiPens are injections, they fall under Part B, which means you pay 20% coinsurance after your deductible rather than a copay.

Your Part B deductible for 2024 is $226 per year. Once you have paid that amount out of your own pocket for Part B services and supplies, Medicare begins paying its share. After that, you pay 20% of what Medicare approves for the EpiPen, and Medicare pays 80%.

The approved amount is set by Medicare and may be lower than the pharmacy's list price. If the pharmacy charges more than Medicare's approved amount, you are responsible only for your 20% of the approved amount — the pharmacy cannot bill you for the difference.

Comparing Costs at Different Pharmacies

The price of an EpiPen or generic epinephrine auto-injector can differ by $50 or more between pharmacies, even after Medicare's discount. This is because pharmacies negotiate their own prices with manufacturers and wholesalers. Before you fill your prescription, call at least two or three pharmacies and ask what your out-of-pocket cost will be.

When you call, have your prescription information ready and tell the pharmacist your Medicare information. Ask specifically about the cost of the brand your doctor prescribed and also ask about generic epinephrine auto-injectors. Some pharmacies offer loyalty programs or discount cards that may lower the price further.

Large chain pharmacies like CVS, Walgreens, and Walmart often have different prices than independent pharmacies in your area. It is worth calling a few to compare. You can also use online tools like GoodRx or SingleCare to see what different pharmacies charge, though you should verify the price by calling the pharmacy directly before you go in.

Medicare Advantage Plans and EpiPen Coverage

If you have a Medicare Advantage plan (Part C), your coverage of EpiPens works differently than Original Medicare. Medicare Advantage plans are run by private insurance companies and set their own rules about which drugs are covered and what you pay. Some plans cover EpiPens with a copay of $10 to $50, while others may require prior authorization or limit how many you can get per year.

You should check your plan's formulary or call your plan's customer service line to find out exactly what you will pay for an EpiPen. The formulary is available on your plan's website or in the materials you received when you enrolled. If your plan does not cover the EpiPen your doctor prescribed, ask your doctor whether a different brand or generic version is covered, or ask your plan whether you can request an exception.

Medigap Plans and EpiPen Coverage

If you have a Medigap policy (also called Medigap supplemental insurance), it may help pay the 20% coinsurance you owe for an EpiPen under Medicare Part B. Medigap plans are standardized, meaning each plan letter (Plan A, Plan B, Plan C, and so on) covers the same benefits no matter which insurance company sells it.

Most Medigap plans cover at least part of your Part B coinsurance. Plans C, D, F, G, M, and N cover 100% of your Part B coinsurance, which means you would pay nothing out of pocket for the EpiPen after your Part B deductible. Plans A, B, K, and L cover a percentage of your coinsurance. Check your Medigap policy documents to see which plan you have and what it covers.

What to Ask Your Doctor

When your doctor prescribes an EpiPen, ask these questions to make sure you understand your coverage and costs:

  • Is there a generic epinephrine auto-injector that would work for my condition, and would it be cheaper?
  • How many EpiPens should I have, and how often do I need to refill them?
  • Are there any other medications I should carry with the EpiPen?
  • If I cannot afford the EpiPen at my pharmacy, are there patient information programs from the manufacturer?

You should also ask your doctor whether you need to carry the EpiPen at all times or only in certain situations. This will help you decide whether to fill multiple prescriptions or keep one at home and one at work.

When to Seek Emergency Care

If you have a severe allergic reaction, use your EpiPen when ready and call 911. Do not wait to see whether the reaction improves on its own. After using an EpiPen, you must go to an emergency room, even if you feel better, because a second reaction can happen hours later.

If you do not have an EpiPen when you need one, go to the emergency room or call 911 right away. Emergency rooms can give you epinephrine through an injection or IV if you are having a severe allergic reaction. Do not delay seeking care because you are worried about cost — emergency care is covered by Medicare.

Frequently Asked Questions

Does Medicare cover EpiPens bought over the counter?

No. Medicare covers EpiPens only when prescribed by a doctor and filled at a pharmacy. Over-the-counter EpiPens are not covered. You must have a prescription to get Medicare coverage.

What if my pharmacy says my EpiPen is not covered?

Call your Medicare plan or Medigap insurance company to confirm whether EpiPens are covered. If there is a question, ask the pharmacy to submit a prior authorization request to your plan. Sometimes a pharmacy's system shows a drug as not covered when it actually is, and prior authorization can resolve this.

Can I get more than one EpiPen at a time?

Yes. Your doctor can prescribe multiple EpiPens, and Medicare will cover them. Many people carry one EpiPen and keep another at home or at work. Ask your doctor how many you should have based on your allergy risk.

Is there a cheaper alternative to EpiPen?

Generic epinephrine auto-injectors are usually cheaper than brand-name EpiPens and work the same way. Ask your doctor whether a generic version would be appropriate for your allergy. Some people also use Auvi-Q, another brand of epinephrine auto-injector, which may have a different price at your pharmacy.

What if I cannot afford my EpiPen even with Medicare?

Talk to your doctor or pharmacist about patient information programs run by the EpiPen manufacturer. These programs may provide EpiPens at no cost or low cost to people who meet income requirements. Your doctor's office may also have samples you can use while you work out payment.