@superfly999

For insurance covering Actemra for PMR---the answer is yes and no.

I'm on Medicare so my monthly IV infusions of Actemra are covered. The self-administered injections aren't covered by Medicare. The infusions are considered "inpatient" medications because they are administered in a "hospital setting" as compared to the injections done at home.

Medicare Part B: Covers medications that need to be given by a healthcare professional in a doctor's office or hospital outpatient setting, such as IV infusions.
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My case was somewhat unusual. When I was working, my employer provided insurance didn't cover Actemra. When I retired on Medicare, my rheumatologist found out that I was a veteran. She said I needed to transfer my medical care to the VA hospital across the street from the University Hospital. She said the VA could prescribe medications that she couldn't prescribe.

I wasn't so excited about going to the VA because I would need to change doctors. My rheumatologist of 15 years said I would be seeing a rheumatologist from the University who also worked at the VA.

At my very first visit to the VA hospital, I met my new rheumatologist. I wasn't prepared for what happened. I thought I would need to start at the beginning by talking about my extensive medical history from the University Hospital. The rheumatologist at the VA hospital interrupted me and said he knew all about me. He said taking Prednisone for the rest of my life wouldn't be a good outcome. He said, "If I was willing to try Actemra, he would try to get the VA to approve it for me." An approval was needed because I was diagnosed with PMR and Actemra isn't FDA approved for PMR.

After Actemra was approved for me, the VA is reimbursed by Medicare for part of the cost of my Actemra infusions and the medication. I don't pay anything for Actemra or for the cost of doing the infusion as long as it is done at the VA Hospital.