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Insurance coverage for Actemra infusion with straight Medicare?
Polymyalgia Rheumatica (PMR) | Last Active: May 14 5:36pm | Replies (30)Comment receiving replies
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. 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.
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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!