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Insurance coverage for Actemra infusion with straight Medicare?
I have had PMR for 4 years, have tried methotrexate and Kevzara but am now on just prednisone. I went off Kevzara due to cost. It was providing some benefit, but was less effective as time went on, plus there were worrisome side effects. Going off the Kevzara has caused a flare-up and I've had to increase prednisone from 5 to 7 mg and still have a fair amount of pain. My rheumie now thinks I probably have GCA as well as PMR and has ordered Actemra infusions. I received a cost estimate of $4500 a month. I was told that it is my job to find out if insurance will cover it. They will bill the whole amount to Medicare, though I also have part D. I have not called Medicare yet, dreading the stress after going through all this with Kevzara. I was told that theoretically Medicare should cover it. I would like to know if anyone in this group has actually had straight Medicare cover Actemra infusions. Thanks for any help on this.
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Oh one more thing, my Dr had told my that Tyenne has some kind of program that helps if people can't afford it and their insurance doesnt cover it. So if medicare doesn't cover it, check with the company that makes Tyenne.
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2 ReactionsI have been receiving Actemra infusions for the past 2 months for GCA. Medicare pays 20%, and my supplement pays the remaining 20%. I didn’t have to do anything except have some bloodwork , the insurance was handled by my Rheumatologist's office. So far, so good, I’m down to 9mg Prednisone.
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1 ReactionMedicare pays 80% not 20.
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1 ReactionSince I have straight Medicare my only choice is the infusion. With injections part D would get involved and there would be significant expense. I like the points @dadcue made about the advantages of the infusions, especially the ease of adjusting the dose if side effects show up.
The only thing I have to do is go to my infusion appointment every 4 weeks. The ability to administer a TCZ infusion in varying doses allows physicians to tailor TCZ therapy to disease activity. I sometimes ask the dose I am getting. Mostly I don't care as long as my symptoms are controlled.
I don't miss trying to decide how much Prednisone to take every day.