Many Medicare drug plans cover generic epinephrine auto-injectors, and some may also cover EpiPen. Medicare coverage through a Part D prescription drug plan depends on the plan details, and other factors.
EpiPen (epinephrine) is a brand-name drug that a doctor may prescribe to treat allergic reactions in adults and children. EpiPen belongs to a drug class known as alpha-adrenergic and beta-adrenergic receptor agonists. Generic versions of epinephrine are also available.
Typically, these drugs come as a solution in a single-dose prefilled autoinjector pen. A person then administers them as a subcutaneous injection or intramuscular injection. Medicare offers some coverage for the medication and the devices. Other cost savings plans may also be available.
This article will discuss EpiPens, epinephrine, allergic reactions, and how the auto-injectors are used. It also looks at Medicare coverage, costs, and possible financial aid.
Glossary of Medicare terms
We may use a few terms in this article that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, this is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
- Out-of-pocket costs: An out-of-pocket cost is the amount a person must pay for medical care when Medicare does not pay the total cost or offer coverage. These costs can include deductibles, coinsurance, copayments, and premiums.
EpiPen is a brand name for a device that injects epinephrine into a person having a severe allergic reaction that may be life-threatening. A company called Mylan owns the brand. It also provides authorized generic devices. This refers to exactly the same product, except the authorized generic does not bear the brand name.
Healthcare providers prescribe epinephrine auto-injectors to people at risk of a severe allergic reaction, which is also known as anaphylaxis or anaphylactic shock. Anaphylaxis can happen quickly, and a person concerned about serious allergic reactions typically keeps an epinephrine injector with them at all times, at home, and at work.
A person can self-administer the injection, or another person can give it. Someone gives the injection by removing a safety cap from the device and then pressing the tip firmly against a person’s outer thigh until the device clicks, injecting the medicine. Many devices also come with a trainer pen that a person can use to practice injecting with.
After receiving an epinephrine injection, the person should go to an emergency facility for further medical care.
EpiPen devices expire at the end of an indicated month, and a person can use this online tool to get expiry alerts by email or text messages.
Epinephrine, also called adrenaline, is a naturally occurring hormone in the body. Artificial epinephrine is used as a medication for allergic reactions.
When a person uses epinephrine, it helps to reverse the symptoms of anaphylaxis. The medication works by reducing swelling and raising blood pressure, which helps to open the airways and allows a person to breathe.
What is anaphylaxis?
Anaphylaxis is a life-threatening allergic reaction to an allergen, and can develop quickly after exposure.
During anaphylaxis, the body releases chemicals that cause blood vessels to open wider and airways to constrict. As a result, a person’s blood pressure drops, and they have trouble breathing.
There are several common triggers and symptoms of allergic reactions, including life-threatening anaphylaxis.
Common triggers
Common triggers of a severe allergic reaction include:
- food
- medication
- insect stings
- latex
Common symptoms
Symptoms of anaphylaxis include:
- difficulty breathing
- hives
- swelling
- hoarse voice
- abdominal pain
- nausea or vomiting
- fast heart rate
- low blood pressure
- dizziness
- fainting
- a feeling of doom
Medicare Part A (hospital insurance) and Part B (medical insurance) provide coverage for prescription drugs in some situations.
Original Medicare
Original Medicare (Part A and Part B) both offer coverage for prescribed drugs. However, they do not do not cover prescription medication when taken at home
Part A covers drugs a person gets during a Medicare-covered hospital stay and other inpatient care. It generally does not pay for any medications. However, if a person receives an EpiPen injection while receiving inpatient care, then Part A will cover it.
Part B generally covers drugs a healthcare professional gives a person in an outpatient setting. Similar to Part A, it generally does not cover any prescriptions a person takes at home. However, if a person has an EpiPen injection while receiving care, such as at an urgent care center, then Part B will cover it.
Part C and Part D
Generally, Medicare coverage for epinephrine auto-injectors, such as EpiPen, will be from Medicare Part C or Part D.
Part C plans, also known as Medicare Advantage, are offered by private companies and may include prescription drug coverage.
Part D plans are also offered by private companies and provide prescription drug coverage.
Medicare Advantage plans with prescription coverage and Part D drug plans each offer a list of covered drugs, also known as formularies. The formularies typically assign covered drugs to tiers, and costs are generally more for drugs in higher tiers.
A person can use this online tool to find Part D plans in their area.
The cost of an EpiPen varies, depending on a person’s healthcare coverage.
Retail cost, without coverage
In 2024, the retail price for a two-pack of EpiPen in the United States may cost roughly $650 to $700. This refers to the amount a person might pay without Medicare or other prescription drug coverage. A coupon might lower the cost.
The U.S. retail price for a two-pack of generic epinephrine may cost around half as much.
Cost with Medicare coverage
Costs for a person enrolled in Medicare Advantage or Medicare Part D varies depending on their plan.
Advantage plan
Many Medicare Advantage plans offer drug coverage. Premiums and other costs will vary by plan and these amounts can change each year. The out-of-pocket limit will also vary by plan. Once a person pays the plan’s limit, the plan fully covers health services for the rest of the calendar year.
Part D
A person enrolled in Part D pays a monthly premium based on their income as shown on their IRS tax return.
If a person has a higher income, they may need to pay more for Medicare drug coverage. For example, if a person earns over $103,000 they will need to pay an extra amount in addition to their plan premium. A person will also need to pay this extra amount if they’re in a Medicare Advantage plan that includes drug coverage. The basic Part D premium for 2023 is $34.70.
There may also be a deductible and coinsurance, depending on a person’s plan, and in which tier the drug is assigned.
In addition, costs may depend on the drug store a person uses, and whether it is out of a plan’s network, or offers standard or preferred cost sharing. The cost may also be different if a person gets mail order prescription drugs.
Assistance with EpiPen costs ranges from savings cards to Medigap plans, as well as low-income plans known as Extra Help.
Mylan savings cards
Mylan owns the EpiPen brand, and offers savings cards that can help save money on the cost of a two-pack refill, and its generic epinephrine injector. However, neither card is available to a person enrolled in Medicare.
A Mylan assistance program helps people pay for EpiPen if their income falls below a certain level. The program is not available to people with Medicare Part D.
Medigap
A person enrolled in original Medicare may also join a Medigap plan, which is supplemental insurance. The plan may help cover out-of-pocket expenses such as deductibles, copays, and coinsurance.
Prior to 2016, some Medigap policies included drug coverage. However, a person cannot enroll in both a Medigap plan and in a Part D drug prescription plan.
This online tool can help a person find a Medigap plan.
Low-income subsidy plan
Depending on a person’s amount of income and assets, they may be eligible for help with Plan D premiums through a low-income subsidy (LIS) program, also known as Extra Help.
Other brands
If a person’s plan does not cover EpiPen or its generics, an individual can select a different brand of epinephrine pen that is available on their Medicare formulary. For example, other brands can include Adrenaclick and Auvi-q.
A doctor may prescribe epinephrine auto-injectors, such as EpiPen, for a person at risk of a severe allergic reaction. Medicare may offer some coverage for the medication.
Part A and B will not cover EpiPens a person uses at home. However, they will cover EpiPens a person receives during a hospital stay or outpatient setting. Part C and Part D may offer prescription drug coverage. Other cost savings plans may also be available.