Does Medicare cover Humira in Oregon?

What Humira is used for

Humira is a TNF blocker you inject under the skin. 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. It's 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?

Humira is not among the drugs CMS has selected for the Medicare Drug Price Negotiation Program so far (the 10 drugs with negotiated prices for 2026, the 15 for 2027 and the 15 selected in January 2026 for 2028).

Generics and biosimilars

FDA licensed the first adalimumab biosimilar in 2016, and several are now on the market. Some are rated interchangeable, meaning a pharmacist may substitute them for Humira where state law allows, the way a generic replaces a brand. FDA's Purple Book lists each one. A biosimilar has no clinically meaningful difference from Humira, according to FDA's standard, but switching is still a conversation to have with your prescriber.

If your plan switches you to a biosimilar

Plans can change which adalimumab products they cover from one year to the next, and can sometimes add a biosimilar mid-year. Your 2027 Annual Notice of Change will say if Humira's coverage changes. If you're told to switch and your prescriber thinks you should stay on Humira, they can request a formulary exception explaining why. If the change is for a new plan year, comparing plans during Open Enrollment (through December 7, 2026) is your other option.

What you pay for Humira in 2027: the out-of-pocket cap

Your cost for Humira depends on your plan: its deductible, the tier it puts the drug on, and whether you use a preferred 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.
• The maximum Part D deductible for 2027 is $700. No plan can set a higher deductible.
• Only covered drugs count. If your plan doesn't cover Humira and you pay cash, or you use a discount card instead of your plan, that spending doesn't count toward the cap.

A specialty drug like Humira can reach the cap within the first fill or two of the year, after which covered Part D drugs cost you nothing for the rest of 2027. That's also why the Medicare Prescription Payment Plan matters most for drugs like this one.

Spreading the cost: the Medicare Prescription Payment Plan

The Medicare Prescription Payment Plan lets you pay your Part D drug costs in monthly bills from your plan across the calendar year instead of all at once at the pharmacy. Medicare.gov says there's no cost to participate, but it doesn't lower your drug costs; it only changes when you pay. It helps most when costs are high early in the year. To join, call your plan or use its website. 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 OHP (Medicaid), a Medicare Savings Program or SSI; otherwise apply through Social Security at 1-800-772-1213 or ssa.gov/extrahelp. See Extra Help in Oregon.

Getting Humira covered in Oregon

If you have both Medicare and OHP, OHP doesn't pay for drugs that Part D covers. The Oregon Health Authority calls this "OHP with Limited Drug": you need a Part D plan (or a Medicare Advantage plan with drug coverage) for Humira, and you qualify for Extra Help automatically. See OHP and Medicare.

Oregon and Washington share Part D region 30, so standalone Part D plans are offered region-wide. For 2027, Oregon has 8 standalone Part D plans from 4 companies, plus Medicare Advantage plans with drug coverage in most counties (61 open to everyone statewide). Each plan has its own formulary, so one plan's coverage of Humira tells you nothing about another's.

Where you live in Oregon changes your choices. CMS data show no Medicare Advantage plan open to everyone in Grant, Harney, Lake, Umatilla or Union counties for 2027 (only employer group plans), and only a special needs plan in Curry County. If you live there, coverage for Humira usually comes from a standalone Part D plan alongside Original Medicare, unless you have employer or other drug coverage. Check your county's numbers on Oregon counties.

How to check whether a plan covers Humira

1. Write down the exact drug. Name, strength and how often you take it. A plan can cover one form of Humira and not another.
2. 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 and any rules.
3. Read the rules next to the drug. Prior authorization, step therapy or quantity limits mean your prescriber may need to send the plan information before it pays.
4. Check your 2027 notice. Your plan's Annual Notice of Change says whether Humira stays on the formulary next year. Open Enrollment runs October 15 to December 7, 2026, for coverage starting January 1, 2027.
5. 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 Humira, 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 your prescriber says waiting could seriously harm your health. New members can usually get a one-time transition supply of a drug they were already taking while they ask for an exception or switch. See How do I appeal a Medicare denial in Oregon?

Sources

• National Library of Medicine — DailyMed: Humira prescribing information (FDA label)
• Medicare.gov — Drug coverage (Part D)
• FDA — Purple Book: licensed biological products, biosimilars and interchangeables
• CMS — Selected drugs and negotiated prices (Medicare Drug Price Negotiation Program)
• CMS — Selected drugs for initial price applicability year 2028 (fact sheet, January 2026)
• CMS — CY 2027 Rate Announcement (2027 Part D out-of-pocket threshold and Extra Help copays)
• Medicare.gov — Medicare Prescription Payment Plan
• Social Security — Extra Help with Medicare prescription drug plan costs
• Medicare.gov — Appeals in Medicare drug plans (coverage determinations and exceptions)
• CMS — Part D plan files record layout (PDP Region 30: Oregon, Washington)
• Oregon Health Authority — OHP and Medicare

Frequently asked questions

Medicare in your Oregon county

Plans, local agents and help, county by county: Multnomah · Washington · Clackamas · Lane · Marion · Jackson · Deschutes · Linn · Douglas · Yamhill · Benton · Polk · Josephine · Umatilla · Klamath · Coos · Columbia · Lincoln · Clatsop · Malheur · All 36 counties →