Does Medicare Cover Humira?

Medicare Benefits Solutions
Nov 5, 2020

With age comes wisdom, knowledge and experience, but as the years add up, so do the chances that you’ll experience conditions like arthritis or autoimmune diseases like rheumatoid arthritis. Arthritis is a condition that affects joints and can make movement difficult and even painful.

Rheumatoid arthritis is similar, but rheumatoid arthritis is actually caused by the immune system attacking the joints. This can lead to swelling, pain, stiffness and other difficult side effects. To alleviate the effects of rheumatoid arthritis and similar autoimmune diseases, many patients rely on drugs like Humira (adalimumab) for help in controlling symptoms and reducing flare-ups.

How Does Humira Work?

Humira works by targeting and blocking a specific type of protein in the body that can cause autoimmune response inflammation. This medication has been shown to be effective against not only rheumatoid arthritis but also ulcerative colitis and Crohn’s Disease. Patients receiving Humira will usually have to receive ongoing treatments, but how many you may need will have to be determined by your primary care physician or autoimmune specialist.

Does Medicare Cover Humira?

In most cases, prescription drug coverage is available through Medicare Part D; however, this only applies to prescription medications that can be purchased from a retail pharmacy and administered at home. Humira is a medication that needs to be injected by a trained medical professional. As such, injections are typically administered in a clinical setting or doctor’s office. This means that instead of Part D, Medicare Part B would apply toward the cost of Humira since the drug is administered in an outpatient setting to Medicare recipients.

Humira might also be covered under Medicare Part A if it is administered as part of a hospital stay or while being cared for in a skilled nursing facility. Medicare Part A is the inpatient benefit and covers all services rendered by the facility to which you are admitted. If a doctor administers Humira in such a setting and he or she is not a part of the hospital’s staff, he or she may bill Medicare recipients separately. Under these circumstances, Medicare Part B may apply to the cost of the Humira administration instead of Part A.

Does Medicare Advantage Cover Humira?

If you have a Medicare Advantage plan, you will likely receive coverage for Humira under the same set of guidelines as issued by Original Medicare. Some Medicare Advantage plan providers have negotiated contracts with certain drug manufacturers, so you may also be able to receive a discount on Humira if your provider allows for it.

As an added bonus, you might be able to take advantage of additional benefits that include physical therapy along with your Medicare Advantage plan enrollment to assist in alleviating the symptoms of rheumatoid arthritis. Many times, Medicare Advantage plans will provide extra coverage options to recipients that are not found in Original Medicare benefits, but each plan is different, so consult with your plan administrator to learn the options that are available to you.