Does Medicare Cover EpiPens? 

Some allergic reactions are merely an annoyance. Slightly dry eyes when the season changes or a few sneezes here and there around flowers may be an inconvenience, but over-the-counter allergy medications reduce or eliminate your symptoms quickly. Unfortunately, more severe allergies can be life-threatening and require prescription medication intervention. If you have Medicare benefits, you may get help paying for medical care you need to treat severe allergies immediately. 

Understanding allergies and anaphylaxis

Thousands of people living in the United States have experienced severe allergic reactions that can be life threatening if not treated immediately. Anaphylaxis can happen when a person’s immune system overreacts to an allergen and releases an overload of chemicals, such as histamine, into the system. 

While most people who have experienced an anaphylactic reaction have been diagnosed with allergies, it’s not impossible to suddenly experience anaphylaxis without prior allergies. 

Some of the most common triggers of sudden severe allergic reactions include:

• Foods like peanuts, nuts, shellfish, fish, eggs, and milk
• Certain medications like penicillin or aspirin
• The venom from insect stings
• Latex
• Exercise
• A combination of multiple factors like exercise and exposure to an allergen

Everyone should be aware of the symptoms of anaphylaxis so they can seek treatment or help someone in need immediately:

• Itchy skin 
• A sudden break out of hives
• Flushed or pale skin
• Low blood pressure
• Difficulty breathing
• Weak, rapid pulse
• Vomiting and/or nausea
• Dizziness or fainting

If you have experienced anaphylaxis, or you are at risk of having a severe allergic reaction, your physician has probably prescribed an auto-injector of epinephrine for you. 

What is EpiPen?

EpiPen is the brand name of an auto-injector that can be used for emergency treatment of severe allergic reactions and anaphylaxis. They are pre-filled pens with a single dose of epinephrine that can be self-administered easily into the thigh muscle. Even though this dose of epinephrine can help you feel better immediately, you should seek medical attention right away to ensure that you don’t have a follow-up reaction. 

Does Medicare cover EpiPen? 

If your health care provider prescribes brand-name EpiPen or the generic equivalent, you must have Medicare Part D prescription drug benefits to get coverage unless you need emergency treatment while you’re a hospital inpatient (Medicare Part A covers this) or during a doctor’s appointment or in an ambulance (Medicare Part B covers this). 

If you have Original Medicare Parts A (hospital insurance) and/or B (medical insurance) , you can enroll in a stand-alone Prescription Drug Plan (Part D) from a private insurance company that works with Medicare. All Medicare Part D plans cover a generic brand of epinephrine auto-injector, and most plans carry the brand-name EpiPen on their formularies (list of covered drugs). 

Costs and benefits may vary among PDP plans. If you’re planning to enroll in a stand-alone Medicare Part D plan, you should check the formularies to ensure that the prescription you prefer is covered before enrolling. If you’re already enrolled in a plan, but it doesn’t cover the prescription you prefer, you can switch plans during a dedicated enrollment period.  

If you’re enrolled in a Medicare Advantage (MA) plan that includes prescription drug benefits, your plan’s formulary should include either the brand-name or generic brand of epinephrine self-injection pens. 

All Medicare prescription drug plans charge a copayment for the drugs listed on their formularies. They place these drugs on tiers (levels) that determine the copayment charge. Most drug formularies have five tiers ranging from the lowest copays on tier one up to tier five for specialty drugs with the highest copay. 

Today, many Medicare Part D plans place EpiPen on the third tier as a preferred brand-name drug. How much you pay depends on your plan, so check with your provider if you aren’t sure. 

How much do EpiPens cost without Medicare coverage? 

If you aren’t enrolled in a Medicare prescription drug plan, you must pay for your EpiPen or epinephrine prescription out-of-pocket. Depending on where you live and which pharmacy you use, you may pay between $650 and $750 for a pack of two brand-name EpiPen auto-injectors with 0.3 mg of epinephrine in each one. A generic brand containing two epinephrine auto-injection pens costs between $320 and $530 with 0.3 mg of epinephrine per pen.