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 can be covered by Medicare, but your out of pocket costs will depend on the type of medication, the way it is administered, and your Medicare coverage.

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 may be taken orally, self-injected, or given by infusion at a doctor’s office. Common DMARDs include Arava, Rheumatrex and Plaquenil.
• Biologics. These are a type of DMRD that targets certain 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. These 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. These 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

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 administered while you are an inpatient.

Medicare Parts A and B do not cover prescription drugs that you take outside a hospital or doctor’s office. This includes pills and injections that you administer yourself. A Medicare Part D prescription drug plan will cover a portion of these costs. However, you may still have copays and deductibles.

Supplemental Medicare Coverage for Rheumatoid Arthritis Patients

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

There are 10 different supplement plans, but plans F and G provide the fullest coverage against out of pocket costs for RA patients.

• Plans F and G will pay the 20 percent coinsurance for Medicare Part B services, including administration of DMARDs at a doctor’s office.
• Additionally, Plans F and G will pay for any “excess charges” billed by your doctor. In most states, providers can bill you an extra 15 percent as excess charges if they are not satisfied with the rates Medicare pays.
• Plan G requires you to meet a deductible ($183 in 2018) before it will begin paying. There is no deductible under Plan F.

Enrolling in a Supplemental Medicare Plan

It is important to enroll in a Medigap plan within six months of the month you are both 65 years old and enrolled in Medicare Part B. If you sign up during this open enrollment period, you are guaranteed coverage, and you will pay the same premium as everyone else.

If you wait, your insurance application will usually be medically underwritten. You may have trouble getting insurance, or you may be charged a high premium because of your RA.

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

Medicare Advantage Plans for Rheumatoid Arthritis

Medicare Advantage Plans, also known as Medicare Part C, are a private insurance substitute for Medicare Parts A and B. Some Medicare Advantage plans also offer prescription drug coverage and other benefits.

However, there is a major difference between Medicare Advantage and Original Medicare/Medigap: Medicare Advantage plans are usually HMOs or PPOs that restrict you to a network of doctors. If you want to see a rheumatoid arthritis specialist who is outside the network, you will pay much higher out of pocket costs. Original Medicare and Medigap don’t have networks – you can see any provider who takes Medicare.

Prescription Drug Plans for Rheumatoid Arthritis Patients

Rheumatoid arthritis medications, particularly biologic DMARDs, can be very expensive. A 2015 study found that the average Part D plan requires patients to pay about 30 percent of the drug’s cost. This meant that patients had an average yearly out-of-pocket costs of more than $2700. There are two ways to keep these costs down:

• Choose the Medicare Part D prescription plan that offers the best coverage for the medications you take at home.
• For expensive DMARDs, talk with your healthcare provider about having the drugs administered at the doctor’s office, where they will be covered by Medicare Part B and Medigap.

Does Medicare Cover Orencia Infusions

Injectable and infused drugs are mostly covered under Medicare when given by a licensed medical provider. 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 is not covered 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 important 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.