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Rheumatoid Arthritis Treatment and Medicare Coverage


Medicare covers a wide range of treatments to slow the progression of rheumatoid arthritis and help with its symptoms. Rheumatoid arthritis treatments can be costly, even with Medicare. If you don’t have supplemental coverage, you may pay thousands of dollars. In this context, we’ll discuss which parts of Medicare will cover Rheumatoid Arthritis treatments.

Does Medicare Cover Rheumatoid Arthritis?

In general, Medicare covers the necessary treatments. But the way it’s covered will depend on the type of care you receive. Part A covers services, procedures, and drugs you receive as an inpatient at a hospital.

For Rheumatoid Arthritis patients, this might include joint replacement surgery or treatment for other medical conditions that develop. Part B covers infusions, outpatient surgeries, physical therapy, and other treatments for Rheumatoid Arthritis. But, you’ll pay a portion of the cost. If your arthritis is severe, Part B could cover a lift chair due to medical necessity.

Part D covers the prescriptions you take at home, including prescription injections. If you have Medicare Advantage, your coverage will be at least as good as Medicare. But your copays and other costs may be different. Many Medicare Advantage plans have prescription coverage built-in.

Also, those with chronic health issues may be eligible for Chronic Care Management that would increase the quality of life.

Biologic Drugs for Rheumatoid Arthritis in the Medicare Program

If you’re diagnosed with Rheumatoid Arthritis, your doctor may recommend that you immediately start treatment with disease-modifying antirheumatic drugs or DMARDs. Biologic DMARDS can bring inflammation under control and halt the progression of your disease. But they are costly.

Does Medicare Cover Enbrel?

Enbrel (etanercept) is a biologic DMARD that belongs to a class of drugs known as TNF inhibitors.

If your doctor prescribes Enbrel, you’ll inject yourself weekly. Because you take Enbrel at home, it falls under Part D. According to Enbrel’s website, the medication’s list price is $1,389 per week for a 50 mg dose.

Although Enbrel offers a copay card to help reduce costs. It claims that 76% end up costing less than $50 a month, while the other 24% cost $469 a month. The amount you pay depends on the specifics of your prescription plan. If you have a limited income, you may qualify for extra help with prescription costs.

Does Medicare Cover Orencia Infusions?

Orencia (abatacept) is also a biologic DMARD; it’s available as an infusion or an injection. If you have an infusion, your doctor will administer the drug through a vein in your arm.

Because you obtain infusions outside the home, Part B covers them. If you have a Medigap plan, it will pay the coinsurance costs.

The sticker price for one Orencia infusion is $3,527, but the manufacturer says Medicare patients pay from $0 to $705. If you have Medicare Advantage, your cost will depend on your plan.

If you take Orencia injections at home, the medication falls under Part D. Your benefits will depend on the kind of plan you have. You could pay as much as $1,500 a month. But, Orencia’s website says more than 80% of Medicare patients pay $25 or less per month.

Does Medicare Pay for Remicade Infusions?

Yes, Medicare covers Remicade Infusions under Part B that’s administered by a physician.

Does Medicare Cover Methotrexate for Rheumatoid Arthritis?

Methotrexate is sold under the brand names Rheumatrex and Trexall. It’s often the first line of defense against rheumatoid Arthritis because it is effective and relatively low in cost. Part D may cover Methotrexate either orally or as an injection; costs depend on your plan.

Does Medicare cover IVIG for Rheumatoid Arthritis?

Part B covers medically necessary intravenous immunoglobulin replacement therapy (IVIG) for severe Rheumatoid Arthritis. A Medicare Supplement plan can cover coinsurance costs.

Does a Medicare Supplement Cover Rheumatoid Arthritis?

Rheumatoid arthritis infusion treatments are costly. If you don’t have supplemental coverage, you could end up paying thousands of dollars a year to manage your condition. Medicare Supplements will help cover most, if not all, of your cost-sharing for Rheumatoid Arthritis treatments.

How to Get Supplemental Medicare Coverage for Rheumatoid Arthritis

Chronic conditions can impact your bones, if you need a bone density test, Medicare has some coverage if your doctor deems it necessary. If you have Rheumatoid Arthritis, you’ll benefit from coverage beyond Medicare. Our agents can explain your options and find the best supplemental plan. Give us a call or fill out our form, and we’ll prepare a free quote for you. We can identify the top carriers with the lowest premiums, and you can make the final choice.

Jagger Esch

Jagger Esch is the Medicare expert for MedicareFAQ and the founder, president, and CEO of Elite Insurance Partners and MedicareFAQ.com. Since the inception of his first company in 2012, he has been dedicated to helping those eligible for Medicare by providing them with resources to educate themselves on all their Medicare options. He is featured in many publications as well as writes regularly for other expert columns regarding Medicare.

38 thoughts on “Rheumatoid Arthritis Treatment and Medicare Coverage

  1. I have been taking enbrel for a while now. Low copays with commercial insurance. However, I am now transitioning to medicare. My research suggests my options are as follows:

    Medicare Advantage with prescription coverage for self injections: These plans cover Enbrel but copay is thousands of dollars per year. Not feasible unless you have more money that you know what to do with.

    Medicare Advantage for infusion of a biosimilar: Medicare advantage will cover infusions under part b but that is at 80%. Under the advantage plans I will be responsible for the remaining 20% for each treatment, still thousands of dollars per year.

    Original medicare with a supplemental plan for infusion of a biosimilar: Original medicare will cover 80% (same as advantage plans). However, the supplemental plan ( I believe) will cover the remaining 20%. I will only need to pay the $233 part B deductible once a year.

    I plan to enroll in original medicare with a supplemental plan. I am going to ask my doctor to switch me to a biosimilar via infusion and my hope is that I can get this treatment with just the $233 annual deductible out of pocket.
    Would you agree this is my best option?

    1. Ian, Medigap Plan G would give you full coverage after meeting your $233 deductible as long as the treatment is deemed medically necessary and administered by your doctor in office. For self-injections, if picked up at the pharmacy, you would be covered under a Part D plan. Plan G is the most comprehensive coverage available. In many cases, Medicare with a supplement is the best route to go. To be sure, you can speak with one of our licensed agents to review your options.

  2. I have a Rituxan infusion once a year for mt RA. The way I’m understanding it from previous posts is that the best route is to enroll in regular medicare part B. Is this correct?

    1. Hi Robert – Part B of Medicare covers Rituxan infusions. If you get a Medicare Advantage plan, this coverage will be included. If you choose a Medicare Supplement (Medigap) plan to pair with your Original Medicare (Parts A and B), you will receive coverage for the 20% coinsurance for which you’re responsible with Original Medicare alone.

  3. What oral RA meds are covered by Medicare? My doc says I have exhausted the infusion-type meds for RA. I have tried Cimzia, SimponiAria, Remacaide, Orencia, and Actemera, none of which has been great. There seem to be new oral RA meds frequently. I have an AARP/UHC SUPPLEMENTAL PLAN

    1. Hi Judy – you’ll need a Part D prescription drug plan to receive coverage for that type of medication. The Annual Enrollment Period is still going on and lasts through December 7, so you have an opportunity to pick one up now. Be sure the formulary for the plan you choose includes the medications your doctor will be prescribing you.

  4. Hi, I have not been able to find an affordable supplement insurance, they tell me it is because I have RA, I thought it didn’t matter if there was an existing medical condition. I am at a lose can you help? Thanks

  5. My spouse will be going on Medicare in a month or two. Deciding between all the plans.
    Receives Inflectra infusions(not for RA) At home but understand will probably go in outpatient once he is under Medicare. Is Medicare advantage or a supplement the better way to go for this? I am not getting a good answer on how much the advantage plan would pay.
    Thanks

    1. Hi Liesl, the best decision for your spouse to make regarding their Medicare coverage depends on their health and budget needs. Inflectra infusions are covered under Medicare Part B. Medicare Supplement plans cover the Part B coinsurance and your spouse would be able to see any practitioner who accepts Medicare (which is the majority in the US). However, their monthly premiums are higher than those for Medicare Advantage plans, which require beneficiaries to stay within a network to receive coverage and reach a maximum out-of-pocket amount before receiving full coverage. Advantage plans include everything Original Medicare (Part A and Part B cover).

    1. Nancy, if the infusion is covered by Original Medicare and deemed medically necessary by your provider, Plan F will pay for the remainder left by Medicare.

  6. Hi. I just retired and very confused with medigap and medical advantage. I use insulin and have a remicade infusion at my doctors office. What program you suggest will be more beneficial to me as to out of pocket expenses Thank you.

    1. Hi Doraida! If you’re concerned with out-of-pocket costs, I would highly recommend you enroll in a Medigap plan & not Medicare Advantage.

  7. Hi, I have to have Rituxan infusions for RA that has not reponded to Methotrexate, Leflunomide, Plaquenil, and other drugs. Infusions to be done in a medical setting. Will the medications and the infusion be covered under Medicare.

    1. Hi Katja! The Rituxan infusions would be covered under Part B. Any medications you pick up at the pharmacy would be covered under Part D. Depending on if and how much is covered depends on what Part D plan you enrolled in.

  8. Hello !
    I am 33 years old and I have been diagnosed with RA since I was 17 years old. I was denied medicaid after I turned 18 years of age and I had to go to Mexico to find a specialist to try and keep my RA stable. As of now my hands are in very bad shape and deformed and it has been very challenging for me to keep my everyday tasks.
    I know I need a hand surgery, but my question is: Can I apply for medicare? or what program for assistance is available?

    Thank you

  9. I would like to know if simponi aria infusions for my RA would be covered under Medicare and I need the Part D which company covers them?
    Thank you!

    1. Hi Sherry! If the infusions were covered, they would fall under Part D. Unfortunately, according to GoodRX, Simponi Aria is not covered by Medicare.

    2. Sherry – I have RA and regular Medicare with a supplemental plan. Infusions are covered under Medicare part B.
      However, If one has a Medicare Advantage Plan, then the infusions are under the “prescription” part with very high copays.

      rgds
      Patty

      1. Thank you so much Patricia for this information! We appreciate it very much!

  10. I have ulcerative colitis and had to switch to Lialda generic before going on Medicare. I was previously on Asacol HD but it was not covered on most Medicare plans or was not affordable. My dr said that I may eventually need to go on Remicade or some type of biological if I start to flare again. What type of plan would give me the most coverage for this? Medicare advantage plans or a medigap with part D?

    1. Hi Kathy! Medigap + Part D will always give you better coverage and lower out-of-pocket costs than Medicare Advantage.

  11. I am trying to find a Biologic that medicare/blue advantage covers that is a low copay, Everything I look at has a high copay, is infusions a better choice with medicare? Just new to all this and have been looking on line for days now, cannot find the answer to this. Hope you can help.

    1. Hi Angie! With Medicare Advantage, it’s up to the carrier what they cover and how much they will cover. You’re going to have high copays with a Medicare Advantage plan for these types of treatments. I’m going to guess even with infusions you’re still going to have a high copay. This is one of the many downfalls of Medicare Advantage plans. You would need to contact your carrier directly to find out. If you had Original Medicare & a Medigap plan, you would pay probably nothing out of pocket with the exception of the annual Part B deductible.

    1. Hi Sharon! It really depends on your specific situation and what codes your doctor uses. Part B may cover it, your doctor should be able to help answer this question. Some Medicare Advantage plans do cover it, as well as some Part D plans. If you have Part D, check your drug formulary. If you have Medicare Advantage, you would need to contact your carrier directly to find out.

  12. I am a former user of Enbrel. While working with ‘regular’ insurance, no issues, co-pay worked great. Now with Medicare only, no co-pay assistance. Cannot afford. Medicare refuses to assist. Options I have applied for are rejected. Daily pills, not covered. Enbrel not covered. Tried the infusion, $550 I paid out of pocket. I was covered in hives, nauseas, and sick for a week. Methotrexate does the same to me without the hives. My only option is to return to work, until I drop? To obtain ‘regular’ insurance. Anyone have suggestions?

    1. Hopefully your doctor has a list of medicare approved biologics that are administered by the nurse at the office. If biologic has to be administered by the nurse at the office the medication goes under part B. All the best

    1. Hi Krista! Any Medicare-approved infusions given in an outpatient setting would be covered under Part B. I would ask your doctor is Medicare will cover Actemra. However, according to GoodRx it doesn’t look like it’s covered.

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