Is Dupixent Covered By Medicare?
Dupixent is the brand name for a medication called dupilumab. It is approved by the Food and Drug Administration (FDA) to treat atopic dermatitis (eczema), asthma, COPD, prurigo nodularis, eosinophilic esophagitis, and allergies.
Dupixent is generally covered by Medicare Part D prescription drug plans. Let’s dig into the details.
How does Medicare cover Dupixent?
To understand your coverage, it's helpful to look at how different parts of Medicare cover Dupixent.
Original Medicare
Original Medicare (made up of Part A & Part B) doesn’t cover most prescriptions. Part A will cover medications administered during an inpatient hospital stay.
Medicare Part B only covers medications given at a doctor's office, like vaccines and infusions. Dupixent usually doesn’t fall under either category.
Medicare Part D and Medicare Advantage
According to GoodRX, 99% of Medicare Part D prescription drug plans cover Dupixent.
Some Medicare Advantage plans (policies where Medicare is provided by a private insurance company, not the federal government) may also cover Dupixent, but check with your plan to confirm.
What is the cost of Dupixent with Medicare?
Dupixent is an expensive medication that most Medicare Part D plans place in the highest tier of their formulary (Tier 5). This means you'll likely pay more for Dupixent than for more common, lower-tier drugs.
According to data from Dupixent, most Medicare Part D beneficiaries (about 79%) pay between $0 and $100 per month for Dupixent. The remaining 21% pay more than $100 monthly.
The monthly out-of-pocket costs for Dupixent may change throughout the year based on:
Whether you've met your Part D deductible
Which coverage phase you're in
Your plan's pricing for the medication
If you qualify for Extra Help, which lowers prescription drug costs for people with limited income
Without insurance Dupixent can cost thousands of dollars each month. The list price is $3,993.36 per carton, which is what an individual would pay if they don’t have insurance or their insurance doesn’t cover Dupixent.
Dupixent eligibility for Medicare coverage
Many Medicare Part D plans require you to try less expensive medications before they'll cover Dupixent.
This process, called step therapy, means your doctor or healthcare provider must show that other treatments didn't work before your plan will approve Dupixent. Prior authorization may also be required.
What conditions does Dupixent help treat?
Dupixent is approved by the FDA to treat the following skin or respiratory conditions:
Atopic dermatitis (eczema): Dupixent is used to treat moderate-to-severe atopic dermatitis in adults and children 6 months and older with dry, itchy, and red skin that doesn't get better with topical prescription therapies like creams or ointments.
Asthma: Dupixent is an add-on maintenance treatment for moderate-to-severe asthma in adults and children 6 years and older with an eosinophilic phenotype or oral corticosteroid-dependent asthma.
Chronic rhinosinusitis with nasal polyps (CRSwNP): Dupixent treats ongoing nasal and sinus inflammation that causes symptoms like facial pain, congestion, and loss of smell. Doctors prescribe it when other treatments haven't worked well enough.
Eosinophilic esophagitis (EoE): EoE is a condition that causes inflammation in the food pipe (esophagus). This happens when certain white blood cells build up in the esophagus lining.
Prurigo nodularis: Prurigo nodularis is a skin condition that causes itchy, hard bumps on the arms, legs, back, and scalp. These bumps form because of inflammation under the skin.
Chronic obstructive pulmonary disease (COPD): Dupixent helps treat severe COPD (chronic obstructive pulmonary disease) when other treatments haven't worked well enough.
How is Dupixent administered?
Dupixent is injected under the skin. The recommended dose and frequency of Dupixent injections will depend on the condition being treated and the individual patient's needs.
Your healthcare provider should train you on how to give yourself Dupixent injections. Be sure to read the medication instructions and ask your doctor or pharmacist any questions before giving yourself the first injection at home.
Like all medications, Dupixent may cause side effects. Common side effects include:
Redness or soreness where you inject the medication
Eye problems like conjunctivitis and keratitis
Cold sores
Stiff joints
Blood vessel inflammation
Seek medical advice about these possible side effects before starting Dupixent.
Other ways to reduce Dupixent costs
The makers of Dupixent (Sanofi and Regeneron Pharmaceuticals, Inc.) offer a savings and copay card called Dupixent MyWay that could lower your cost to $0 per prescription if you have certain medical insurance.
However, it’s not open to Medicare beneficiaries.
To qualify, you must be:
Commercially insured with a private insurance company, health insurance exchanges, federal employee plans, or state employee plans
A resident of the 50 United States, the District of Columbia, Puerto Rico, Guam, or the USVI
Prescribed Dupixent for a condition approved by the U.S. Food and Drug Administration
If you can't use the Dupixent MyWay program, you may qualify for Medicare Extra Help, which lowers prescription drug costs for Medicare beneficiaries with limited income and resources.
Those who are eligible for both Medicare and Medicaid may also be able to receive substantial assistance with prescription drug costs under Medicare Part D.
Want to discuss Medicare’s coverage of Dupixent?
Speak with one of our independent Medicare Advisors, who are eager to help you understand your coverage and how to get the most out of Medicare. Get in touch by calling us at (855) 900-2427 or picking a time to chat.