Navigating Medicare Coverage, EpiPen, and Medicare Part D

• EpiPen (epinephrine) is an injectable medication used as an emergency treatment for serious allergic reactions. Epipen is injected into a large muscle, like the outer thigh.

• While Original Medicare does not include prescription drug coverage, beneficiaries can enroll in a separate drug plan known as Medicare Part D. Many Medicare Advantage plans also include prescription drug coverage.

• Most Medicare Part D drug plans include coverage for generic epinephrine. This does not include brand name EpiPen in most cases.

• There are ways to help individuals combat high prescription drug costs, including GoodRx, Medicaid, Extra Help program, etc.

EpiPen (epinephrine) is an injectable medication used to treat severe allergic reactions in emergency situations. For those who need to use EpiPen regularly, it should be kept on them at all times. That said, EpiPen is an extremely expensive medication. Thankfully, 98% of Medicare prescription drug plans cover the generic version of EpiPen, epinephrine. 

Read on below to learn more about Medicare coverage, EpiPen, and how Medicare drug plans work in general.

In emergency situations, EpiPen (epinephrine) is an injectable medication used to treat severe allergic reactions promptly after exposure. Some of the symptoms of a severe reaction include difficulty breathing, swollen face, lips or tongue, wheezing, vomiting, tightness in the throat or hives and redness of the skin. 

How to Administer EpiPen

When prescribed an EpiPen you should familiarize yourself with the instructions on how to use it. Often the box includes a practice unit without the needle or medicine so that the person can safely practice beforehand. EpiPen is injected into the outer middle thigh at the sign of a severe allergic reaction. Clothing does not need to be removed. The leg needs to be stationary during the injection. After injecting EpiPen, the patient should immediately call 911. Please do not try to drive after using an EpiPen.

Brand name EpiPen and its generic version should never be injected into the buttock, intravenously, digits, hands, or feet. Doing so can increase the risk of serious side effects.

EpiPen Dosage Information

Each autoinjector EpiPen is intended for single use. The dosage is 0.3 mg.

Epinephrine is also sold in vials as a generic medication.

Warnings and Side Effects

There are a number of side effects that may be possible after injecting epinephrine. Let a healthcare provider know immediately if the following are experienced:

• Anxiety

• Racing heart

• Abnormal or decreased touch sensation

• Arm, back, or jaw pain

• Hives

• Dizziness

Medicare beneficiaries should always inform their medical provider of their medical history to help avoid adverse outcomes.

How Expensive is EpiPen?

Without insurance, the brand name EpiPen runs around $687.49 on average. Generic EpiPen costs $398.81 on average.

As a reminder, Original Medicare only consists of Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). These Medicare Parts do not include coverage for prescription drugs such as EpiPen. As such, those who only have an Original Medicare plan need to enroll in a Medicare drug plan, known as Medicare Part D, in order to receive coverage for prescription drugs. 

That said, a limited number of drugs administered in a doctor’s office or hospital outpatient setting may be covered under Medicare Part B in certain situations. This may include EpiPen or epinephrine. 

Note: Learn more about outpatient drugs and Medicare Part B at this resource.

Medicare Part D is Medicare’s prescription drug coverage. Most Medicare drug plans include a monthly premium, yearly deductible, copayments, and coinsurance. The overall costs will vary depending on which Part D prescription drug plan is chosen. Factors that contribute to costs include: 

• Prescriptions: What prescriptions a beneficiary needs and whether they’re on the drug plan’s list of covered medications, known as the plan’s formulary can affect cost.

• Medication Tier: What tier the medication is in can affect the plan’s cost. The higher the tier, the more expensive a medication usually is. Most plans have five tiers. Tier information is provided on the plan’s formulary. 

• Drug Benefit Phase: Which drug benefit phase the beneficiary is in can affect the plan’s cost, i.e. whether they’ve paid their deductible or if they’re in the catastrophic coverage phase.

• Pharmacy: What pharmacy type and location impact Part D’s cost. 

• Medicare Extra Help Enrollment: Whether a beneficiary is enrolled in the Medicare Extra Help program can impact their Part D cost.

Medicare enrollees are encouraged to compare Medicare prescription drug plans to find the best option for them.

Note: Learn more about Medicare Part D costs at this resource.

Does Medicare Part D Cover EpiPen? 

Many Medicare Part D plans cover generic EpiPen, not the name brand version. That said, coverage and cost will still depend on the specific drug plan chosen. Copays for epinephrine range from $0 to $182 at the very most. How much a beneficiary needs to pay out-of-pocket will be dependent on what drug benefit stage they are in.

Quantity limits and prior authorization may apply. A quantity limit is how much medication a beneficiary can fill at one time. 

Generic EpiPen is typically a Tier 3 medication. 

Medicare Advantage plans, also known as Medicare Part C or MA plans, may include prescription drug benefits. MA plans are a type of Medicare supplement plan and are provided by private insurance companies that are Medicare-approved. Medicare Part C plans consist of the standard Medicare coverage (Medicare Part A and Medicare Part B), in addition to other healthcare benefits including vision, hearing, and prescription drugs. 

Exact benefits will vary per plan. MA plan beneficiaries should confirm extra benefits with their insurance company.

Do Medicare Advantage Plans Cover EpiPen? 

Some Medicare Part C plans may cover EpiPen. However, it will depend on the specific MA plan chosen since not all Medicare Advantage plans include coverage for prescription drugs. 

If an MA plan does include prescription drug coverage, beneficiaries can look at their plan’s formulary for a list of covered drugs to see if EpiPen is included.

Out-of-pocket costs for prescription medications can add up quickly, even with coverage. Some large retail pharmacies, such as Walmart, offer cheap prescription medication plans. However, individual pharmacies will need to be contacted to confirm.

As well, there are a number of programs that can help Medicare beneficiaries with these drug costs, however.

Extra Help Program 

The Extra Help Program is a Medicare program to help beneficiaries with limited income or resources pay for a Medicare prescription drug plan. Some people automatically will qualify for Extra Help, such as those who qualify for the QMB program, SLMB, or QI program under a Medicare Savings Program.

Those who do not automatically qualify can apply here.

SHIP

The State Health Insurance Assistance Program (SHIP) is a national program that helps Medicare beneficiaries, caregivers, and family members make informed choices about their Medicare benefits and navigate all of their options. 

Note: Learn more about SHIP at this resource.

GoodRx

GoodRx is both a website and mobile application that finds discount pricing for prescription medications. Visit its EpiPen page to learn more.

Medicaid (Dual Eligibles)

Beneficiaries eligible for the Medicaid ​“Dual Eligibles” program will be eligible to use the Medicaid Drug Rebate Program (MDRP). This program helps to offset the Federal and state costs for prescription drugs. 

Note: Learn more about Medicaid Drug Rebate Program at this resource.

PACE

PACE stands for Program of All-Inclusive Care for the Elderly. It is a Medicare and Medicaid program that provides all the care and services covered by Medicare and Medicaid if authorized by someone’s health care team. This includes prescription drugs. Those in a PACE program do not need to enroll in a separate Medicare Part D drug plan.

Note: Learn more about PACE at this resource.

Medigap/​MedSupp

Medigap or MedSupp plans are supplemental Medicare plans that intend to ​“fill in the gaps” of Original Medicare. Medigap plans often help with deductible, copayment, and coinsurance payments. 

When it comes to prescription drugs, someone cannot be enrolled in both a Medicare prescription drug plan as well as a have a Medigap policy with drug coverage. Learn more about Medigap and Medicare drug coverage at this resource.