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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.
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1 ReactionThe 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.
Medicare now has a $2000 Annual cap on prescription drugs. I have part D through Cigna and had to pay $2000 and all my drugs have zero co-pay for the rest of this year. Medicare has also announced. They will do this in 2026 also
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1 ReactionMedicare now has a $2000 Annual cap on prescription drugs. I have part D through Cigna and had to pay $2000 and all my drugs have zero co-pay for the rest of this year. Medicare has also announced. They will do this in 2026 also. I do the injections myself biweekly at home and have been doing it for four months, but I have some breakthrough symptoms and I'm wondering if the infusions are more effective.
This is good to know that the cap is working. I have part D with Aetna. When I did my research in December and January neither they nor any Part D plan in my county would cover Kevzara or Actemra. They did offer me a "lowered" price of $1600/month but Medicare told me the $2000 cap did not apply if the plan has the drug on their non-covered list. It made me mad that a drug is Medicare-approved for a disease but Part D plans won't cover it. From what you say it may have taken awhile for the $2000 cap to take effect. Aetna has called me a couple of times and left messages to call them if I am having any trouble with my plan but I have not called back. The Actemra infusions are paid through Medicare so that cuts the Part D plan out. I haven't started them yet. I am thoroughly disgusted with our hybrid for-profit and non-profit medical care system!
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1 ReactionHello Linda7
I just started my infusions of the bio similar to Actemra, Tyenne. I have Kaiser senior advantage which is Kaiser with Medicare. So it’s not exactly straight Medicare, I guess. But it is not costing me anything so I consider myself very fortunate to get this.
I'm glad to see the Advantage plans covering this. It looks like straight Medicare will cover it for me as well. I hope it works for you!