Actemra coverage on Medicare in California?

I have the same ... traditional Medicare with United HealthCare supplement Plan F or whatever one doesn't pay the first $200 Medicare deductible every year. I don't pay the $200 deductible either as long as I go to the VA.

In 2025, I'm considering switching to an Advantage Plan for veterans who get their care at the VA. Supposedly United HealthCare will pay me money to get on that Advantage Plan ... how ridiculous is that? They say since I get my medications and care from the VA that saves them a lot of money.

The VA does my Actemra infusion at no cost to me but it costs taxpayers. I pay taxes too so I figure I pay for it too somehow in the grand scheme of things. The VA can't bill Medicare for the cost of the infusion but the VA gets some reimbursement from my Medicare supplement. I'm not quite sure how it all works but everyone seems happy.

I've learned a little about how Medicare coverage for Actemra works in California. It it probably similarly elsewhere, but some of what I write below is specialized to Kaiser Permanente Northern California (KPNC), which serves the San Francisco Bay area. Bottom line: for those on Medicare, it looks like by using KPNC's Medicare Part D plan, Actemra injections are covered and are cheaper than the alternative, Actemra infusions. This does not include the effect of support plans that have income testing.

There are two ways to get Actemra:
1) Infusion (administered at a medical center)
2) Self injections.
This matters because these two routes are paid for by different parts of Medicare, with different rates and maximums.

INFUSIONS of Actemra, which are given once a month at a medical center, are considered medical procedures and are therefore covered by Medicare Part B (the medical insurance part for things like doctor visits and outpatient care). There is a 20% copay, which I'm told ends up being about $700-$800/month. If you are at KPNC on Medicare, there are 2 plans. One has a $3900 annual out of pocket maximum, and the other has $6000. So you pay the $700-$800/month for Actemra until you hit the out of pocket maximum. Based solely on this, the plan that has a $3900 out of pocket max is cheaper, even though it has a $70/month premium and the other plan's premium is $0. The total would be $4740 for a year of Actemra. But it turns out injections are less, perhaps much less.

INJECTIONS of Actemra, which are self-administered, typically once a week or every other week, are considered drugs, and are therefore covered by Medicare Part D (the part that covers drugs). There are many suppliers of Medicare Part D, and if you sign up with KPNC for Medicare Part A&B, you can still sign up for Part D elsewhere. However, looking at the US government's Medicare.gov site, it turns out that the KPNC Part D plan is very competitive in benefits, and it does cover Actemra, and further, Part D is includes at no additional cost when you get Part A&B coverage from KPNC. There is an out of pocket maximum for the KPNC Part D plan, which I am told is about $3300 for 2024, and was scheduled to go to $3500 for 2025. However, I am told, due to new government regulations, that the out of pocket maximum is likely to be at most $2000 for 2025, and this will be true for any Part D plan offered anywhere. The details of copays on Kaiser's Part D are complex (initially a 33% copay, followed by $20% once the total drug cost to KPNC has been $5000, so after about 6 weeks for Acterma, then no copay). But you'll never pay more that the out of pocket maximum for the Part D plan, so either $3500 or $2000 for a year of Actemra in 2025, depending on when the government regulations begin to be enforced.

None of the above includes the normal monthly payments for Medicare since you will have to pay those no matter what you do, even if you don't get Actemra. The costs I've stated above are the additional costs to get Actemra.

You have done your homework. Someone started a thread on Tyenne. Recently FDA approved and much cheaper. Although it would probably still hit the out of pocket maximum.

@redboat
Hello red boat!
I have Kaiser Senior Advantage in Southern California which is a medicare/Kaiser plan.
My rheumatologist wants to start me on Actemra soon. I’m assuming this is no problem with medicare! If I find out differently I will let you know.

@redboat
My doctor did talk about taking the injections of Actemra, not the infusion. The cost is probably why— I appreciate all the research you did in regards to this! Looks like I will be getting the injections, but I will check to see if it is different for Southern California Kaiser. I also was a Kaiser employee for 20 years under a union contract which negotiated co-pays for drugs, etc so this might factor into my particular coverage. I know I have the same co-pays I had when I was working.

@redboat has an incredible story about how high his inflammation markers were. I'm not sure about how he was diagnosed with PMR but it was considered to be an extreme case. His response to Actemra was remarkable and as far as I know he is off prednisone and symptom free now.

@dadcue
My head is spinning from all the information I’m getting, lol 😂
The only thing I can say is that so far I’m happy with the coverage I have!!
Thanks for all your info!

@dadcue
I would be in big trouble if they capped benefits with only 5 medications! 😂

Sometimes I don't know how much of a benefit there is to take many medications. My view point comes from having to give medications to patients every morning. I would need to carefully get their medications ready for them every day. They were very sick people so they might need to take 20 or more medications first thing every morning. I just wasn't sure all the medications were helping that much. Sometimes I felt like I was contributing to their demise by expecting people to take so many medications.

Actemra is the one medications that seems to do me a lot of good. I am back down to taking 2 medications now not counting Actemra. My remaining medications are "as needed" or for "prevention" or totally optional.

There were so many people that had no idea what medications they took. All they knew was a doctor told them they needed the medication but they didn't know why. The 5 medication limit was more about putting a limit on doctors from prescribing so many medications.

When I was diagnosed with PMR and "other things" I was in the same boat for a long time. Many of my medications were prescribed to me to treat Prednisone side effects. I was giving myself more than 10 medications and I wasn't so sure all my medications were doing that much good.

Thanks @jlo2252 ! Assuming Kaiser Senior Advantage in Southern California is like Northern California's, Actemra should be covered. In NorCal, Medicare Part D coverage, which is needed to offset costs for Actemra, is included at no extra cost at Kaiser. There is a new alternative, called Tyenne, which I understand less expensive. But Tyenne and Actemra are both quite expensive. Without insurance or any offsets, Actemra is something like $40,000/year.