Actemra coverage on Medicare in California?

Welcome to the Medicare system of health insurance for retirees.

I don't know all the details but the following link might help you navigate Medicare. Most states have State Health Insurance Programs (S.H.I.P.)
https://www.shiphelp.org/about-medicare/regional-ship-location/california
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Doing self injections of these biologics are considered "outpatient" medications. They are not always covered by Medicare Advantage Policies. If they are covered, the co-payment is likely to be costly.

The same costly co-payments are true for drug plans which have a separate premium in addition to a Medicare Supplement premium.

Medicare does cover infusions of biologics because they are considered "inpatient" medications and can't be self-administered. Medicare will pay 80% of the combined cost to administer the medication plus the medication itself. A Medicare supplement should cover the remaining 20% depending on the type of supplement you choose.

Actemra can be given by a monthly infusion so it would be covered by Medicare so long as it is given for an FDA approved indication. Actemra is FDA approved for the treatment of GCA so it would be covered by Medicare + Supplement. Actemra would not be covered for PMR because it isn't FDA approved for PMR.

I don't think Kevzara can be given as an infusion. Kevzara is given by a self administered injection so not covered unless an outpatient drug plan covers it.

There are assistance programs to help cover the cost of Actemra. I don't know how the assistance programs work with Medicare but I bet if you call the number they would have information.
https://www.actemra.com/ra/financial-support/assistance-options.html

Make sure to check into whether an advantage plan is the best option. Mayo Phoenix does not take advantage plans. I see other groups are starting to not take advantage. There is also a penalty if you do not sign up for the supplement at time of eligibility. My understanding the requirements for for a supplement are dictated to all carriers. Not really much shopping. I use Humana because they offer silver sneakers. My gym membership is covered. They have a zillion different drug plans. They are all different and different costs. One at $10 month might cover just as much as another at $40 month. Best to shop your drug plan.

Mayo doesn't accept Medicare reimbursement rates but they accept Medicare. At least that is my understanding.

Mayo probably accepts Advantage Plans but those plans limit the network of providers you can see. You can probably go to Mayo but be faced with additional costs because of being out of network. Mayo might also charge more than the Medicare approved amounts for health care services so both of these factors would discourage me from going to Mayo if I had an Advantage Plan.

The following discussion talks about this. It is all very confusing. There is nothing about Medicare that is easy to explain or to understand.
https://connect.mayoclinic.org/discussion/does-mayo-clinic-take-medicare/

/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."

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.

It's very simple to find out which Medicare part D drug plans cover Actemra. Just go on Medicare.gov, enter your medication list, and it will tell you which plan will give you the best coverage and what it will cost. At the end of last year, before I got on Kevzara, I just entered that medication and found out the best plan and what my co-pay would be for that drug. It was $300 per month. I applied for patient assistance through the drug company and get it for free but I have to reapply at the end of the year. I believe that yearly part D drug costs will be capped at $2000 starting next year.

"I believe that yearly part D drug costs will be capped at $2000 starting next year."

I hope this is the patient's "out of pocket cost" will be capped at $2,000 per year.

I once proposed the idea that the number of medications a patient could have should be capped at a 5 medication limit and no more than 5. It would be the patient's decision to decide which medications worked the best for them. If a new one came along that exceeded a 5 medication limit they would need to stop one before starting the new one. I thought things would be simpler that way. I said it as a joke but I think some people thought it was a serious proposal.

After I was diagnosed with PMR and started on prednisone, my medication list exploded to over ten medications. Some people said I was over my limit. After I started Actemra and discontinued prednisone my medication list went back down to 2 medications not counting my Actemra infusion. I said my Actemra infusion shouldn't be counted since my Actemra infusion was administered in a hospital setting. An infusion given in a "hospital setting" wasn't considered to be an outpatient prescription medication according to Medicare. This is true even though I go to the hospital to get the infusion for an hour and I go home after every infusion.

The whole problem with medication costs is about who is going to pay for them.

Sometimes I think people wouldn't need so many medications if they were only prescribed just a few that worked well and only the medications which didn't cause so many side effects.

I have had 2 surgeries with hospital stay, GCA biopsy, 1 emergency room visit, and dozens of tests, scans, blood work. office visits etc and not one bill from Mayo. Medicare rules are they have to provide you with an ABN if the procedure is not covered. They did ask me to sign one ABN. I didnt sign it so they skipped that test. As long as you have Medicare original they follow the Medicare billing requirements. I did get one bill for $26. They asked me if I needed a Ibuprofen or anything for pain. I said yes. Medicare said administering of OTC medications was not covered. I appealed but lost the appeal. I just paid the $26. I have used Mayo for my urologist, cardiologist, and rheumatologist. Trying to make an appointment with Gastrologist but they wont accept new patients.

Do you go to Mayo in Phoenix for most everything? Do you have traditional Medicare or an Advantage Plan?

I have traditional Medicare with a supplement. I'm not sure if I need the coverage but I'm willing to contribute to the system.

I currently get care at the VA hospital across the street from the University hospital where I worked before I retired. The doctors I see at the VA also work for the University. I don't ever get billed for anything at the VA.

I still miss the University health insurance that was provided at no cost to the employee. I miss getting care at the University Hospital because I received excellent care there. The University hospital was "self insured" because the insurance company only processed the claims. The University hospital had an administrative board that waived many rules for employees as long as the test or procedure was done at the University Hospital.

The patient population I worked with as a nurse received a lot of their medical care funded through donations and research grants. Patient's who volunteered for research studies wouldn't be billed for tests related to research protocols.

The "usual and customary" tests and procedures were billed to the patient's insurance company. It would get complicated and sometimes it was hard to decide what was research related and therefore "experimental" and what was "the current standards for care."

I think Mayo does a lot of research too and does the same thing or something similar. Sometimes it was a source of conflict but many times I could get things paid through a research grant even if it wasn't purely research.

That is why I usually say it is just a matter of finding someone who is willing to pay the medical costs. On the other hand, I wasn't sure that all the research was "good research." There were plenty of disputes regarding these matters.

I agree. Been through lots of research with my wife. I dont really have much positive to say about it but someone has to do it. Yes I have Medicare original A&B. Thats what about 80 -20. Then I have Humana plan F as supplement. That picks up whatever Medicare doesnt. Costs me about $250 month for Humana each for my wife and I. I also have no deductibles with Plan F. I think the newer supplement plan is G. Then you pay the deductibles. Plan F supplement the first requirement is that it must be covered by Medicare. So just because you have the supplement doesnt mean everything is covered. The supplement just picks up the deductibles and the 20% copay. The good thing is that Mayo agrees to what Medicare will cover. I think that is a requirement for any Dr that takes Medicare. I use Mayo for all my focused issues. I have a GP that I see for regular Dr visits. I use an office that is more holistic type stuff but still a Dr. I have had some gut issues but Mayo wont allow any new patients . For at least the last year. I am seeing a highly rated private practice gastrologist but its half the attention you get by going to Mayo. I have been satisfied on my Medicare coverage. My wife and I have had zero out of pocket.