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Insurance coverage for Actemra infusion with straight Medicare?
Polymyalgia Rheumatica (PMR) | Last Active: 21 hours ago | Replies (25)Comment receiving replies
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.
Replies to "Hello, In regards to your doctor office saying it’s up to yo to find out if..."
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.
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.
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I agree that it is up to the doctor to get approval. I have Medicare Advantage, and I called them to ask about the process for getting Actemra approved. They said the doctor had to request it. I saw my rheumatologist on Friday, and I mentioned that I needed to have the Actemra approved again in August. She said to remind her in early July to request the approval, and acted like it isn't a big deal.