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Actemra coverage on Medicare in California?
Polymyalgia Rheumatica (PMR) | Last Active: Sep 23 8:24am | Replies (28)Comment receiving replies
/Here is the info they send out every year. This was for 2024. I should be getting another one since enrollment is coming up. Probably the same thing your saying/
"Reminder: Mayo Clinic in Arizona accepts Original Medicare, is not in network on Medicare Advantage Plans
At Mayo Clinic, our patients are at the center of everything we do, and your trust is very important to us. Sharing information is one way to help ensure we continue to be trusted partners for your healthcare needs.
Beginning in mid-October, it will be time to select healthcare coverage for 2024. We want to remind you that Mayo Clinic in Arizona is not currently in network for any Medicare Advantage Plans.*
While this is not new, it is an important reminder: Medicare Advantage Plans do not include care at Mayo Clinic in Arizona, even when the plan indicates that you can be seen at any facility that accepts Medicare.
We continue to accept Original Medicare (sometimes referred to as Traditional Medicare) including Parts A, B, and D, and supplement plans. If you choose to enroll in a Medicare Advantage Plan, we can provide your medical records to the in-network facility you select for care.
If you are out-of-network, we will complete any active treatment but cannot begin new episodes of care or schedule new, unrelated appointments after January 1, 2024.
Medicare Advantage Plans are managed by commercial insurance companies on behalf of Medicare and offer a specific network of contracted medical providers and hospitals, which do not include Mayo Clinic in Arizona. These plans are required to have a substantial network of qualified providers to accommodate their members' medical needs."
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It basically says the same thing I was trying to explain. I know very little about this stuff but I sometimes needed to submit information when a patient's insurance didn't want to pay for things.
The thing I'm not sure about is if Mayo accepts Medicare reimbursement rates or not. Someone told me once that Mayo doesn't.
I know Mayo does a lot of tests and "extensive work-ups" which is good. However, Medicare insurance might not pay for all the tests and procedures.
Many tests and medical procedures aren't considered to be what is "usual and customary" in insurance lingo for the condition being treated. This is where "prior-authorization" comes into play because insurance companies say much of what medical providers do isn't necessary.
This is also where FDA approval for Actemra to treat GCA and Kevzara to treat PMR is so important. These medications are no longer considered to be "experimental treatments" for these conditions which is the usual reason why insurance companies don't cover the cost of certain medications.
Now medical insurance companies might say less expensive alternatives are equally effective and need to be tried first. For example, if methotrexate doesn't work maybe the insurance company will pay for a biologic. That is just another excuse if you ask me. I think insurance companies would prefer people to be treated with prednisone. Many patients think prednisone is the "only medication that works" for PMR/GCA but this is starting to change.