Medicare covers Dupixent, but only under Part D prescription drug plans, and your out-of-pocket cost depends on which plan you chose and where you are in the coverage year.
Dupixent (dupilumab) is a biologic medication used to treat moderate to severe eczema, asthma, and chronic rhinosinusitis. Because it is a prescription drug rather than a medical service, Medicare Part B does not cover it. Instead, coverage comes through Part D, the prescription drug benefit you selected when you enrolled in Medicare or during the annual open enrollment period.
Whether your specific plan covers Dupixent and what you pay for it depends on three things: whether your plan's formulary includes it, what tier it is placed on, and whether you have met your deductible and annual out-of-pocket maximum for the year.
Key Takeaways
- Dupixent is covered under Medicare Part D prescription drug plans, not Part B, so your coverage depends on which Part D plan you chose.
- Not all Part D plans cover Dupixent, and those that do may place it on a higher cost tier, meaning you pay more out of pocket.
- Your actual cost changes throughout the year as you move through the deductible, initial coverage, and coverage gap phases.
- You can call your Part D plan directly or use the Medicare Plan Finder tool to check whether Dupixent is on your plan's formulary before filling a prescription.
- If your plan does not cover Dupixent or the cost is too high, you may be able to switch to a different Part D plan during the annual open enrollment period in October through December.
How Part D coverage works for Dupixent
Part D plans are run by private insurance companies under contract with Medicare. Each plan creates its own formulary — the list of drugs it covers — and decides which tier each drug goes on. Tier 1 drugs (generics) cost the least. Tier 2 drugs (preferred brand-name) cost more. Tier 3 and higher tiers cost even more, and some plans may not cover a drug at all.
Dupixent is a brand-name biologic with no generic equivalent, so it typically lands on Tier 3 or Tier 4 when it is covered. This means your copay or coinsurance will be higher than for a generic or preferred brand-name drug. Some plans may require prior authorization — meaning your doctor must submit paperwork to the plan showing the drug is medically necessary — before the plan will pay for it.
Your actual out-of-pocket cost also depends on where you are in the coverage year. In the deductible phase, you pay the full price until you meet your deductible. Once you meet it, you enter the initial coverage phase and pay your copay or coinsurance. If your total drug costs reach the coverage gap threshold (also called the "donut hole"), you enter the coverage gap and pay a higher percentage until you reach your annual out-of-pocket maximum.
Checking whether your plan covers Dupixent
The fastest way to find out is to call your Part D plan directly. The phone number is on the back of your Medicare card or in your plan's welcome materials. Tell them you want to know if Dupixent is on the formulary, what tier it is on, and whether prior authorization is required. Ask them to give you the exact copay or coinsurance amount based on your plan's cost structure.
You can also use the Medicare Plan Finder tool on Medicare.gov. Enter your zip code, select your current plan, and search for "Dupixent" in the drug search box. The tool will show you the tier, copay amount, and any restrictions. Keep in mind that the Plan Finder updates monthly, so if you checked it weeks ago, the information may have changed.
If you have not yet chosen a Part D plan or are in the annual open enrollment period, you can use the Plan Finder to compare plans side by side. Search for Dupixent in each plan you are considering to see which ones cover it and at what cost. This comparison can help you choose a plan that fits your medication needs.
What to do if your plan does not cover Dupixent
If your current plan does not cover Dupixent at all, or if the cost is too high, you have options. During the annual open enrollment period — October 15 through December 7 each year — you can switch to a different Part D plan that does cover it. You can also switch if you may have access to for a special enrollment period, such as after a major life event or if you move to a new state.
Before you switch, compare the total cost of switching plans. A plan with lower Dupixent costs might have higher copays for your other medications, so add up what you would pay for all your prescriptions under each plan. The Medicare Plan Finder tool shows the estimated annual cost for all your drugs under each plan, which makes this comparison easier.
Another option is to ask your doctor whether there is a different medication that treats your condition and is covered at a lower cost by your current plan. Your doctor can also submit a request for an exception to your plan, asking them to cover Dupixent or place it on a lower tier. Plans sometimes grant exceptions if your doctor documents that you have tried other treatments and they did not work.
Manufacturer information and copay programs
Dupilumab's manufacturer, Sanofi, runs a copay information program called the Dupixent Copay Card. If you have Part D coverage for Dupixent, you may be able to use this card to reduce your copay to as little as $0 per month, depending on your plan and income. The program is available to people with Medicare as long as your plan covers the drug.
To learn about you may have access to and how to enroll, visit the Dupixent website or call the number on your Dupixent prescription bottle. You will need to provide proof of your Part D coverage. The copay card does not change your plan's coverage — it straightforward reduces what you pay at the pharmacy.
Some community health centers and patient advocacy organizations also offer financial support for people who cannot afford their medications. Ask your doctor's office whether they know of any programs in your area, or search for "patient information programs" plus your medication name online.
When to talk to your doctor about coverage
If you are newly diagnosed with a condition that Dupixent treats, talk to your doctor before filling the prescription. Tell them which Part D plan you have and ask them to check whether it covers Dupixent. If it does not, ask whether they recommend switching plans or trying a different medication first.
If you have been taking Dupixent and your plan coverage changes — for example, if your plan moves Dupixent to a higher tier or removes it from the formulary — contact your doctor right away. Do not stop taking the medication on your own. Your doctor can help you decide whether to switch plans, request an exception, or try a different treatment.
If you are having trouble affording Dupixent even with your Part D coverage and the copay card, tell your doctor. They may be able to help you find other resources or work with your plan to reduce your costs.
Frequently Asked Questions
Does Medicare Part B ever cover Dupixent?
No. Part B covers injectable medications that are administered in a doctor's office or hospital, but Dupixent is a self-injected medication that you use at home. It is always covered under Part D, not Part B, if it is covered at all.
What if I cannot afford the copay even with the manufacturer's copay card?
Tell your doctor and your Part D plan. Your doctor can request a formulary exception, asking the plan to cover Dupixent at a lower cost tier. You can also contact your state's pharmaceutical information program or a patient advocacy organization for your condition — many offer grants or loans to help with medication costs.
Can I use a GoodRx coupon or discount card instead of my Part D coverage?
You can, but usually you should not. Part D coverage is almost always cheaper than a discount card for expensive biologic drugs like Dupixent. Compare the price your Part D plan charges with the GoodRx price before you decide. If you use a discount card instead of Part D, it does not count toward your deductible or out-of-pocket maximum.
What happens to my Dupixent coverage if I switch from Original Medicare to a Medicare Advantage plan?
Medicare Advantage plans include prescription drug coverage, but each plan has its own formulary. You will need to check whether your new plan covers Dupixent and at what cost. You can switch back to Original Medicare and a separate Part D plan during the annual open enrollment period if your Advantage plan does not cover the drug you need.
Do I have to pay for Dupixent out of pocket and then get reimbursed by Medicare?
No. Your Part D plan pays the pharmacy directly, and you pay only your copay or coinsurance at the time you fill the prescription. You do not pay the full price upfront and then wait for reimbursement.