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Insurance coverage for Actemra infusion with straight Medicare?
Polymyalgia Rheumatica (PMR) | Last Active: 16 hours ago | Replies (25)Comment receiving replies
I was diagnosed with PMR/GCA in July 2024. Started on 60 mg. of prednisone. In early December, I had tapered to 10 mg. Major flare during the holidays and all my initial PMR/GCA symptoms returned. In early January, my inflammatory markers were high. I asked my rheumatologist to order Actemra infusions. Initially, she wanted to order Kevzara, but my Part D insurance doesn't cover it. She ordered the infusions and I get them every 4 weeks. I have had a huge improvement in my health.
To answer your question, Medicare will pay for infusions because they are administered in a 'medical setting'. Medicare had to approve the order, but it only took a week or so. I was getting my infusions at an infusion center in Florida and they were $2600 per dose. If you go the self injection route, you have to deal with Part D and the possible co-pays that come with that.
Ask your rheumie to order Actemra. I don't think you need to chase this down. PMR is stressful enough. You don't need the additional stress in trying to get an answer from someone on the phone (if they even answer the phone).
Replies to "I was diagnosed with PMR/GCA in July 2024. Started on 60 mg. of prednisone. In early..."
Thanks to you and to others who have answered. I now am fairly confident that Medicare will cover the Tyenne ( Actemra biosimilar) infusions. The order was put in and they called me to schedule but I held off because of my doubts. I'm going to wait until my next lab draw and MD visit in about a month. That way I'll have a good baseline on the labs since the Kevzara I recently got off had caused some abnormalities.
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The problem is that Actemra is only FDA approved for GCA and not always authorized for treating PMR. Some doctors will assume there is underlying GCA or "presumptive GCA" for people who are diagnosed with PMR. Since there isn't any definitive way to diagnose either PMR or GCA it is mostly diagnosed based on symptoms and presenting characteristics.
A rapid response to prednisone tends to "confirm" the diagnosis of PMR/GCA but that is misleading at best. Most all inflammatory conditions will respond to Prednisone. Other than PMR/GCA, there aren't that many conditions still being treated with "long term" Prednisone because of the side effects of long term use. Until relatively recently, Prednisone was called the "only option" for PMR/GCA so people get left on Prednisone forever sometimes.
Kevzara is FDA approved for PMR but it only comes in an injectable form. I would think Kevzara will have an infusible formulation in the future. However, there needs to be more research submitted to the FDA for an infusible formulation of Kevzara to be FDA approved for PMR.