← Return to Insurance coverage for Actemra infusion with straight Medicare?

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@dadcue

That's good to know. I was thinking it would just depend on how it is coded. I don't think there are any definitive tests that confirm GCA, It mostly depends on a doctor saying you have GCA and coding it that way. I hope it works. Seems like you know how the system works.

Actemra probably works for PMR even though it isn't FDA approved for PMR. Actemra is off patent and biosimilars are already appearing. That should bring down the cost. Since Actemra is no longer patented, I doubt any more research will be done to get it FDA approved for anything else.

I started out doing Actemra injections when it was first approved for me. I was switched to Actemra infusions when I had a surgery that was pending. I needed to be off Actemra for a month before surgery and a month after surgery. I didn't think I could go 2 months without an injection.

Going 2 months between infusions was probably doable. Seven weeks was the longest I have gone without an infusion of Actemra I don't think the infusions have to be done exactly every 4 weeks. I sometimes go 5 or 6 weeks without having a flare but my inflammation markers start to increase.

I ended up not doing the surgery mostly because Actemra works so well for me. It controls the inflammation everywhere including my spine. When I told my rheumatologist the infusions worked better than the injections, he thought it was interesting. He wondered about infusions versus injections. He said I could keep doing the infusions if I wanted to,

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Replies to "That's good to know. I was thinking it would just depend on how it is coded...."

I actually know quite a bit about coding and how the system works from 25 years as a physical therapist. Sometimes I forget to apply my knowledge to my own case. As far as coding goes it was not a fun part of my job. Reimbursement depends on the codes used so there was pressure when I admitted a patient to find every last diagnosis that applied and hopefully ones that brought in the most money to the agency, which was nonprofit but struggled to break even!