What Humira is used for
Humira is an injectable biologic (a TNF blocker). Its FDA label covers rheumatoid arthritis, juvenile idiopathic arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn's disease, ulcerative colitis, plaque psoriasis, hidradenitis suppurativa and uveitis.
This page explains Medicare coverage only. Questions about whether Humira is right for you belong with your prescriber.
Which part of Medicare covers Humira
Humira is a pen or prefilled syringe you use at home, so it's a Part D drug. Medicare.gov says Part B usually covers drugs you wouldn't typically give yourself, like those given in a doctor's office. Humira is a specialty drug, so plans may require prior authorization and may require you to fill it at a specialty pharmacy that ships to your home.
Is Humira on Medicare's negotiated-price list?
No. Humira is not among the drugs CMS has selected for the Medicare Drug Price Negotiation Program so far: the 10 drugs with negotiated prices since January 1, 2026, the 15 with negotiated prices starting January 1, 2027, and the 15 CMS selected on January 27, 2026, for prices that take effect in 2028. The program only selects drugs without generic or biosimilar competition, and Humira has biosimilars.
Biosimilars
FDA licensed the first adalimumab biosimilar in 2016, and several are now on the market; FDA's Purple Book lists each one. CMS describes a biosimilar as highly similar to the original biologic, with no clinically meaningful differences in safety and effectiveness. Some adalimumab biosimilars are rated interchangeable, which matters at a North Carolina pharmacy:
- Substitution. Under G.S. 90-85.28, a pharmacist filling a prescription written for Humira may dispense an FDA-rated interchangeable biosimilar instead, unless your prescriber signs "Dispense as Written" or says so when calling in the prescription. The pharmacist may switch only if the price to you is lower.
- Your prescriber is told. Within five business days of dispensing a biologic, the pharmacy must tell your prescriber which product and manufacturer you got (not needed when no interchangeable product exists or a refill doesn't change products).
Your plan's formulary may favor one adalimumab product over another. If your plan switches products for 2027, the Annual Notice of Change says so; talk with your prescriber before you switch.
What you pay for Humira in 2027: the out-of-pocket cap
Your cost depends on your plan: its deductible, the tier it puts the drug on, and whether you use a preferred or specialty pharmacy. This site doesn't list plan costs; your plan's formulary and Evidence of Coverage do. What Medicare sets for everyone with Part D is the limit:
- 2027 out-of-pocket cap: $2,400 (it was $2,100 in 2026). Once what you pay for covered Part D drugs (deductible, copays and coinsurance) reaches the cap, you pay nothing more for covered Part D drugs for the rest of 2027. With a specialty drug, you can reach it early in the year.
- The maximum Part D deductible for 2027 is $700. No plan can set a higher one.
- Only covered drugs count. If your plan doesn't cover the product you use and you pay cash, that spending doesn't count toward the cap.
Spreading the cost: the Medicare Prescription Payment Plan
If you'd reach the cap in January or February, the Medicare Prescription Payment Plan can spread those costs into monthly bills from your plan across the calendar year instead of large pharmacy payments up front. Every Part D plan and Medicare Advantage plan with drug coverage offers it. Medicare.gov says there's no cost to participate, but it doesn't lower your drug costs; it only changes when you pay. More in What is the Medicare Prescription Payment Plan?
Extra Help with Humira
Extra Help (the Low-Income Subsidy) is a federal program that lowers Part D premiums, deductibles and copays. For 2027, CMS caps Extra Help copays for covered drugs at $5.80 for a generic and $14.40 for a brand-name drug, and some people with full Medicaid pay less. You get Extra Help automatically if you have full NC Medicaid, a Medicare Savings Program (North Carolina calls them MQB) or SSI. Otherwise, apply through Social Security at ssa.gov/extrahelp or 1-800-772-1213 (TTY 1-800-325-0778). North Carolina has no general state drug-assistance program for seniors. See Extra Help in North Carolina.
Getting Humira covered in North Carolina
North Carolina is a Part D region of its own (PDP Region 08), so each standalone Part D plan sold here is offered in all 100 counties. For 2027, CMS lists 11 standalone Part D plans from 6 companies in the state, and every county has Medicare Advantage plans open to everyone, from 11 in Carteret County to 57 in Guilford County. Each plan has its own formulary and specialty-pharmacy rules. Your county's numbers are on North Carolina counties.
TRICARE For Life. If you're a military retiree (North Carolina is home to Fort Bragg, Camp Lejeune, Seymour Johnson Air Force Base and Marine Corps Air Station Cherry Point), CMS says TRICARE drug coverage is creditable, and that for most people with TRICARE, unless they qualify for Extra Help, Medicare drug coverage isn't cost effective. If you have TRICARE and join a Medicare drug plan, the Medicare plan pays first. Check with TRICARE before changing anything. See military, veterans and TRICARE in North Carolina.
State Health Plan retirees. In the Plan's Base Plan or Enhanced Plan (group Medicare Advantage plans with Part D), Humira or a biosimilar is covered under the Plan's drug list. The Plan says joining an outside Part D or Medicare Advantage plan disenrolls you from its group plan and moves you to the 70/30 Plan. See State Health Plan retirees and Medicare.
Medicare and NC Medicaid. If you have both, Medicare drug coverage, not NC Medicaid, pays for Part D drugs like Humira, and you get Extra Help automatically. If your Medicare Advantage plan ends in 2027, you have a special enrollment period through February 28, 2027; choose new drug coverage by December 31, 2026, so a specialty refill isn't interrupted. See plans ending in 2027.
How to check whether a plan covers Humira
- Write down the exact product. Humira or a named biosimilar, the strength, pen or syringe, and how often you inject.
- Look it up in each plan's formulary. Enter your drugs and ZIP code on PlanMatch or Medicare.gov's Plan Finder to see which plans list Humira or a biosimilar and any rules.
- Read the rules next to the drug. Prior authorization is common for specialty drugs; your prescriber may need to resend it to a new plan.
- Ask about the specialty pharmacy. Find out which pharmacy the plan uses and how it ships, especially if you live in a rural county.
- Get help if you want it. You can request a call from a licensed insurance agent, who can compare plans from the companies they work with, or call 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048) for information on all of your options.
If your plan doesn't cover the product you need, you or your prescriber can ask for a coverage determination or a formulary exception. Once the plan has your prescriber's supporting statement, it generally must decide within 72 hours, or 24 hours if waiting could seriously harm your health. New members can usually get a transition supply while they ask. See How do I appeal a Medicare denial in North Carolina?
Sources
- National Library of Medicine — DailyMed: Humira prescribing information (FDA label)
- Medicare.gov — Drug coverage (Part D)
- Medicare.gov — Prescription drugs (outpatient) under Part B
- Medicare.gov — Your Guide to Medicare Drug Coverage (CMS Product 11109; biosimilars, TRICARE)
- CMS — Selected drugs and negotiated prices (Medicare Drug Price Negotiation Program)
- CMS — Selected drugs for initial price applicability year 2028 (fact sheet, January 2026)
- FDA — Purple Book: licensed biological products, biosimilars and interchangeables
- North Carolina General Statutes — G.S. 90-85.28, selection of equivalent drugs and interchangeable biological products
- CMS — CY 2027 Rate Announcement (2027 Part D out-of-pocket threshold, deductible and Extra Help copays)
- Medicare.gov — Medicare Prescription Payment Plan
- Social Security — Extra Help with Medicare prescription drug plan costs
- eCFR — 42 CFR 423.120 (formularies and transition fills)
- CMS — Prescription drug coverage (CY 2027 Landscape files: North Carolina is PDP Region 08)
- State Health Plan — Retiree presentation (group Medicare Advantage and outside Medicare plans)
Frequently asked questions
Can a North Carolina pharmacy give me a biosimilar instead of Humira?
If the biosimilar is FDA-rated interchangeable, yes, unless your prescriber marks the prescription Dispense as Written. North Carolina law (G.S. 90-85.28) then requires the pharmacy to tell your prescriber which product you got.
Is Humira covered by Part B?
Usually not. Humira is a pen or syringe you inject at home, so it's a Part D drug. Part B generally covers drugs you wouldn't give yourself, given in a doctor's office.
Does the 2027 Part D out-of-pocket cap apply to Humira?
Yes, when your Part D plan covers it. In 2027, once you've paid $2,400 for covered Part D drugs, you pay nothing more for covered Part D drugs for the rest of the year.
Is Humira on Medicare's negotiated-price list?
No. Humira isn't among the drugs CMS has selected so far, for 2026, 2027 or 2028. Adalimumab biosimilars are on the market, and CMS selects only drugs without generic or biosimilar competition.
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