Insurance coverage for Actemra infusion with straight Medicare?

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).

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.

Hello, In regards to your doctor office saying it’s up to yo to find out if Medicare covers your Actemra infusions seems strange to me. Recently my rheumatologist put me on Kevzara but said it would take a couple weeks to for insurance approval. After a couple weeks the special pharmacy called and said it was approved. All this to say that I can’t remember when either myself or my wife had been told it was up to us to get the prior approval for anything medical . We have 8 grown children, so that’s a lot of approvals.
In 2025 the Medicare deductible max was lowered to $2000. Considerably less than before….. Hope the best for you.

Hello, In regards to your doctor office saying it’s up to yo to find out if Medicare covers your Actemra infusions seems strange to me. Recently my rheumatologist put me on Kevzara but said it would take a couple weeks to for insurance approval. After a couple weeks the special pharmacy called and said it was approved. All this to say that I can’t remember when either myself or my wife had been told it was up to us to get the prior approval for anything medical . We have 8 grown children, so that’s a lot of approvals.
In 2025 the Medicare deductible max was lowered to $2000. Considerably less than before….. Hope the best for you.

It's slightly complicated. I chose to have straight Medicare rather than an Advantage plan for several reasons. I worked as a P.T. for 25 years and I saw how poorly patients were often treated by advantage plans. They are for-profit companies trying to do everything the cheapest way, with networks of preferred providers, limitations on out-of-local area coverage, ability to deny coverage, etc. You have less choice in many cases. I know they work out for a lot of people. I am in favor of single payor non-profit medical care, so I'm walking my talk with my choice. In the case of the infusion, I don't have to wait for authorization because there is no pre-authorization but the doctor has to use the correct code to get it covered. If it is a covered Medicare item there is no chance for denial. This is the first expensive item I have needed so I asked for an estimate of cost in case I somehow ended up getting billed. The billing people are just covering their butts when they told me they can't make any guarantees about what insurers will do. It turned out the doctor coded it correctly, I didn't need to worry about it. If I had less knowledge and experience I probably wouldn't have worried about it.

Do you have a Medicare Supplement? It adds to the cost of your insurance but a supplement decreases what you have to pay your health care provider? Medicare only pays for 80% of the hospital costs.

Hello, In regards to your doctor office saying it’s up to yo to find out if Medicare covers your Actemra infusions seems strange to me. Recently my rheumatologist put me on Kevzara but said it would take a couple weeks to for insurance approval. After a couple weeks the special pharmacy called and said it was approved. All this to say that I can’t remember when either myself or my wife had been told it was up to us to get the prior approval for anything medical . We have 8 grown children, so that’s a lot of approvals.
In 2025 the Medicare deductible max was lowered to $2000. Considerably less than before….. Hope the best for you.

Very unusual that your doctors office comments like this. They want you for a patient, they want to treat you, they want to get paid or reimbursed for their services and yet they don’t assist with a pharmacy consult to see if the drug interacts with anything you are taking and in the pharmacy consult they can tell you what insurance covers your copay etc etc. ask for a pharmacy consult specific to rheumatoid issues if possible. My rheumatologist does this with every new medication I try. Part of the serve and there should be no charge for this.

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.