Medicare covers Humira, but the amount you pay depends on which Medicare plan you have and whether you meet your plan's requirements

Humira (adalimumab) is a biologic medication used to treat rheumatoid arthritis, psoriasis, Crohn's disease, ulcerative colitis, and other inflammatory conditions. Medicare Part D (prescription drug coverage) covers Humira, but you will likely pay a portion of the cost yourself. The exact amount depends on your specific plan, your deductible, and which tier Humira falls on in that plan's formulary — the list of covered drugs.

If you have Original Medicare (Part A and B) without Part D, you will pay the full cost of Humira out of pocket unless you join a Part D plan or a Medicare Advantage plan that includes drug coverage. Most people with Medicare who take Humira use either a standalone Part D plan paired with Original Medicare, or a Medicare Advantage plan that includes prescription drug coverage.

Key Takeaways

  • Humira is covered by Medicare Part D plans, but your out-of-pocket cost depends on your plan's formulary tier and your annual deductible.
  • You must be enrolled in a Part D plan or a Medicare Advantage plan with drug coverage to have Medicare pay any portion of Humira's cost.
  • Humira is a specialty drug on most formularies, which means higher copays or coinsurance than standard medications.
  • The manufacturer offers a copay information program that can reduce your out-of-pocket cost to as little as $5 per month if you meet income requirements.
  • Your coverage and costs can change each year, so review your plan's formulary during the annual enrollment period (October 15 to December 7).

How Medicare Part D covers Humira

Part D plans place drugs into tiers, usually ranging from tier 1 (lowest cost) to tier 5 (highest cost). Humira typically sits on tier 3 or tier 4 — the specialty drug tiers — because it is an injectable biologic medication that costs several thousand dollars per month. This means your copay or coinsurance will be higher than for a standard oral medication.

Your actual cost depends on where you are in the coverage year. In the initial coverage phase, you pay a copay or coinsurance percentage for each prescription. Once your total drug spending (what you and your plan pay combined) reaches a certain amount — $5,850 in 2024, though this changes yearly — you enter the coverage gap, sometimes called the "donut hole." In the gap, you pay a larger share of the cost until your out-of-pocket spending reaches the catastrophic threshold. After that, Medicare pays most of the cost.

Because Humira is expensive, many people reach the coverage gap and catastrophic coverage phases within a few months. This can actually work in your favor: once you hit catastrophic coverage, your costs drop significantly.

Medicare Advantage plans and Humira

If you have a Medicare Advantage plan (Part C) that includes prescription drug coverage, Humira coverage works differently than with Part D. Each Advantage plan sets its own formulary and cost-sharing rules. Some plans cover Humira with a copay; others use coinsurance (a percentage of the drug's cost). A few plans may require prior authorization — meaning your doctor must get approval from the plan before you fill the prescription.

The advantage of Medicare Advantage is that your out-of-pocket costs are usually capped at an annual maximum, whereas Part D has no such cap. However, you are limited to the plan's network of pharmacies and doctors. If your current rheumatologist is not in the plan's network, switching to that plan could mean finding a new doctor.

Before you enroll in or switch to a Medicare Advantage plan, check whether Humira is on the formulary and what your copay or coinsurance would be. You can do this on Medicare.gov or by calling the plan directly.

The manufacturer's copay information program

AbbVie, the company that makes Humira, runs a copay information program called the Humira Complete program. If you meet the income requirements — generally household income at or below 400% of the federal poverty level — you may pay as little as $5 per month for Humira, regardless of your plan's copay or coinsurance.

To use this program, you must be enrolled in a Medicare Part D or Medicare Advantage plan with drug coverage. The program covers the difference between your plan's copay and the $5 you pay. You will need to enroll in the program by calling 1-844-HUMIRA1 (1-844-486-4721) or visiting the AbbVie website. Enrollment is free and takes about 10 minutes.

Keep in mind that copay information programs can change or end. Check the program's website or call before your prescription is due to confirm you are still covered.

Prior authorization and step therapy requirements

Some Medicare plans require prior authorization before they will cover Humira. This means your doctor must submit a request to the plan, usually including information about your diagnosis and why Humira is medically necessary. The plan then approves or denies the request, typically within 24 to 72 hours.

A few plans also use step therapy, which requires you to try and fail on a cheaper medication first before the plan will cover Humira. If your plan has step therapy, your doctor can sometimes request an exception if there is a medical reason you cannot take the first-line drug.

You can find out whether your plan requires prior authorization or step therapy by reviewing your plan documents, calling the plan's customer service number, or asking your pharmacy when you try to fill the prescription. If prior authorization is needed, your doctor's office can usually handle the paperwork.

What to do if your plan does not cover Humira

If your current Part D plan does not cover Humira, or if the copay is too high, you have options. During the annual enrollment period (October 15 to December 7), you can switch to a different Part D plan or Medicare Advantage plan that does cover Humira at a lower cost. You can compare plans on Medicare.gov by entering Humira and your zip code.

If you need Humira before the enrollment period, you may be able to request a coverage exception from your current plan. Ask your doctor to submit a letter explaining why Humira is medically necessary and why alternatives will not work. The plan must respond within 72 hours. Approval is not may provide, but it is worth trying if you are in urgent need.

You can also look into whether you may have access to for Medicaid or other state pharmaceutical information programs, which sometimes cover drugs that Medicare does not. Contact your state Medicaid office or your State Health Insurance information Program (SHIP) for more information.

Checking your coverage before you fill a prescription

Before you fill a Humira prescription, call your pharmacy or log into your plan's website to check your exact copay or coinsurance. Ask the pharmacy to tell you your deductible status and whether you have already entered the coverage gap. This will help you understand what you will owe.

If the cost is higher than you expected, ask your doctor whether there are other treatment options, or ask about the manufacturer's copay information program. You can also call your plan's customer service line to ask about prior authorization requirements or coverage exceptions.

Frequently Asked Questions

Does Original Medicare Part A and B cover Humira without Part D?

No. Original Medicare does not cover outpatient prescription drugs. You must enroll in a Part D plan or a Medicare Advantage plan with drug coverage to have Medicare help pay for Humira. If you do not have drug coverage, you will pay the full cost out of pocket.

How much does Humira cost with Medicare?

Costs vary widely depending on your plan, deductible, and where you are in the coverage year. Copays for specialty drugs like Humira typically range from $100 to $500 per month, but can be higher. The manufacturer's copay information program can reduce this to $5 per month if you meet income requirements.

Can I use GoodRx or other discount programs with Medicare?

You cannot use GoodRx or similar discount cards while enrolled in Medicare Part D — it is against the rules. However, you can use the manufacturer's copay information program, which is specifically designed for people with Medicare. Some state pharmaceutical information programs also offer discounts.

What happens if I reach the coverage gap?

In the coverage gap, you pay a larger share of Humira's cost until your out-of-pocket spending reaches the catastrophic threshold (about $7,050 in 2024). After that, Medicare pays most of the cost and your copay drops significantly. Because Humira is expensive, many people reach catastrophic coverage within a few months.

Can my doctor appeal if my plan denies coverage for Humira?

Yes. Your doctor can request a coverage exception or appeal a denial by submitting a letter explaining the medical necessity. The plan must respond within 72 hours for urgent requests. If the plan denies the appeal, you can file a grievance with Medicare.