Rheumatoid Arthritis Treatment and Medicare Coverage

Rheumatoid arthritis, or RA, is an autoimmune disease that attacks the joints, causing inflammation, pain, swelling, and damage. RA typically strikes people between the ages of 30 and 60, and it’s more common in women than in men.

Rheumatoid arthritis is different than osteoarthritis, a degenerative joint disease that is most common in people over 65.

Healthcare providers usually prescribe medications to control the debilitating effects of rheumatoid arthritis. These medications a Part D plan can cover; but, your out of pocket costs depend on the type of drugs, the way you take medicine, and your policy.

Treatment for Rheumatoid Arthritis

Some of the most common medications for rheumatoid arthritis include:

• Disease-modifying antirheumatic drugs, or DMARDs. These drugs halt the destructive immune response and can slow or stop the disease and prevent permanent joint damage. DMARDs can be oral, self-injection, or by infusion at a doctor’s office. Common DMARDs include Arava, Rheumatrex, and Plaquenil.
• Biologics. These are a type of DMRD that targets specific steps in the inflammatory process. Biologics have been known to slow or stop RA even when other treatments have failed. Biologics are either injected or given as an infusion at a doctor’s office. Brand names include Humira, Orencia, Remicade, and Enbrel.
• Corticosteroid medications, such as prednisone, can relieve inflammation and pain, but because of potential side effects, they are usually only prescribed short-term.
• Nonsteroidal anti-inflammatory drugs such as ibuprofen may be prescribed or purchased over the counter to help with pain and inflammation.

If you have permanent joint damage that limits your ability to function, your doctor may also recommend joint replacement surgery.

Rheumatoid Arthritis and Medicare

Part B will typically cover 80 percent of the cost of doctor visits and rheumatoid arthritis drugs administered in a doctor’s office. Part A will cover hospitalization for joint replacement surgery, inpatient rehabilitation afterward, and medication while you’re an inpatient.

Parts A and B don’t cover drugs that you take outside a hospital or doctor’s office. Including pills and injections that you administer yourself.

Part D plans cover a portion of these costs. However, you may still have copays and deductibles.

Supplemental Medicare Coverage for Rheumatoid Arthritis Patients

If you have RA and only have Parts A and B, you may find yourself paying thousands of dollars out of pocket every year. That’s why a “Medigap” plan is so important.

There are ten different supplement plans, but plans F and G provide the fullest coverage against out of pocket costs for RA patients.

• Plan F and G pay the 20 percent coinsurance for Part B services, including administration of DMARDs at a doctor’s office.
• Plans F and G pay for “excess charges” by your doctor. In most states, doctors can bill you an extra 15% as excess charges if they don’t agree with the Medicare rate.
• Plan G requires you to meet a deductible ($197 in 2020) before paying. There is no deductible under Plan F.

Enrolling in a Supplemental Medicare Plan

It is essential to enroll in a Medigap plan within six months of turning 65 and enrolling in Part B. If you sign up during this Open Enrollment Period, you have Guarantee Issue (GI) rights and pay the lowest monthly amount.

If you wait, your insurance application goes through medical underwriting. You may have trouble getting insurance, or you may pay a high premium.

If you qualify for Medicare because of a disability, you may be able to enroll in a Medicare Supplement plan before you are 65. Still, your premiums will be higher than for people over 65.

Medicare Advantage Plans for Rheumatoid Arthritis

Medicare Advantage Plans are Part C; this is a  private insurance alternative to Parts A and B. Some Part C plans offer drug coverage and other benefits. However, there is a significant difference between Medicare Advantage and Medigap.

Medicare Advantage plans are usually HMOs or PPOs that restrict you to specific doctors. If you want to see a rheumatoid arthritis specialist who is outside the network, you pay much higher out of pocket costs. Medigap allows you to see any provider who takes Medicare.

Prescription Drug Plans for Rheumatoid Arthritis Patients

Rheumatoid arthritis medications, particularly biologic DMARDs, can be costly. A 2015 study found that the average Part D plan requires patients to pay about 30 percent of the drug’s cost. Meaning, patients had average yearly out-of-pocket costs of more than $2700.

There are two ways to keep these costs down:

• Choose the Part D plan that offers the best coverage for your medications
• For expensive DMARDs, talk with your healthcare provider about having the drugs at the doctor’s office, where Medicare Part B and Medigap will cover them.

Does Medicare Cover Orencia Infusions

Injectable and infused drugs are mostly covered under Medicare when given by a medical doctor. Almost 90% of plans will cover the Orencia. Check with your healthcare provider to verify what Medicare billing code they’ll be using.

Does Medicare Cover Enbrel

Enbrel doesn’t have coverage by most Medicare plans; however, there are manufacturer coupons you can use to help with your out of pocket costs.

Find Supplemental Medicare Coverage

When you’re managing a chronic condition like RA, it’s essential to keep your healthcare costs down. We understand, and that’s why we search the top-rated insurance companies for you – with no obligation – to find you the best rates on supplemental Medicare coverage.

Just call the number above or fill out our form to get started. Our agents are here to answer all your questions regarding Rheumatoid Arthritis and Medicare coverage.