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Rheumatoid Arthritis Treatment and Medicare Coverage

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

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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.

Medicare 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.

Medicare 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.

Medicare Part D prescription drug plans cover 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. Medicare Advantage plans may offer prescription coverage.

Also, those with chronic health issues may be eligible for Chronic Care Management, which could help with 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 $1,762.34 per week for a 50 mg dose.

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Enbrel offers a copay card through Amgen SupportPlus to help reduce costs. 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 $4,043, but the manufacturer says most Medicare patients pay from $0 to $808.

If you take Orencia injections at home, the medication falls under Part D. Your benefits will depend on the kind of plan you have.

Does Medicare Pay for Remicade Infusions?

Yes, Medicare covers Remicade Infusions under Part B because it’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.

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Does a Medicare Supplement Plan 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 Supplement plans can 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 may benefit from coverage beyond Original Medicare. Our agents can explain your options and help you find the right coverage for your healthcare needs. Give us a call or fill out our online rate form, to get some quotes on plan premiums in your area.

Sources

MedicareFAQ is dedicated to providing you with authentic and trustworthy Medicare information. We have strict sourcing guidelines and work diligently to serve our readers with accurate and up-to-date content.

  1. Johns Hopkins Arthritis Center. Accessed August 2023.
    https://www.hopkinsarthritis.org/arthritis-info/rheumatoid-arthritis/ra-treatment/
  2. Enbrel. Accessed August 2023.
    https://www.enbrel.com/en/enbrel-cost
  3. Orencia. Accessed August 2023.
    https://www.bmspricinginformation.com/orenciaIV
Kayla Hopkins

Kayla Hopkins

Content Editor
Kayla Hopkins is an accomplished writer and Medicare guru serving as the Editor of MedicareFAQ.com. Upon completing her Communications degree from Ohio University, Kayla dedicated her time to understanding the ever-evolving landscape of healthcare. With her extensive background as a Licensed Medicare Insurance Agent, she brings a wealth of knowledge and expertise to her writing.
Ashlee Zareczny

Ashlee Zareczny

Compliance Manager
Ashlee Zareczny is the Compliance Manager for MedicareFAQ. As a licensed Medicare agent in all 50 states, she is dedicated to educating those eligible for Medicare by providing the necessary resources and tools. Additionally, Ashlee trains new and tenured Medicare agents on CMS compliance guidelines. Ashlee is a Medicare expert who specializes in Medicare Supplement, Medicare Advantage, and Medicare Part D education.

55 thoughts on "Rheumatoid Arthritis Treatment and Medicare Coverage"

  1. I am about to start Medicare Parts A and B on 1/1/2024, I am going to select the Medigap coverage but I would like to know about the drug formularies for Part D coverage. I am currently on Amjevita with a co-pay assist bringing my cost to $0. So, would I lose this co-pay assist when I sign up for Part D? I am not really getting results from Amjevita and have tried 23 other drugs and biologics for RA. I would like to see which drugs each Part D plan covers to see if there is anything else I can try. Thank you.

    1. Hello Rose,

      Each Medicare Part D plan has a different formulary depending on where you live. Contact one of our agents and we can help you find the right coverage for your medication needs.

  2. I have Medicare & BCBS. I have RA and my doctor wants me to start taking Humira now. Do you think I can get this covered under my insurance? I took lab tests today as required for them. I hope they will be covered. Thank you for your time.

    1. Great question, Judy! To receive coverage for Humira, you will need to be sure your prescription drug coverage covers the drug. This can be found on your drug plans formulary.

    1. Lisa, it does look like there are several Medicare Part D plans that cover Xeljan. However, it is a Tier 5 medication, so the copayment is high on most plans.

  3. I will be turning 65 in October and will be on Medicare. And am very confused. I am on Rinvoq with RA. I was told by Blue Advantage that I will have to pay 30% which I can not afford. What should I do?

    1. Lynne, I recommend checking with other carriers to determine which carrier covers your drug at the best price. I always say, be loyal to your wallet, not a carrier. Since each plan is regulated by Medicare, it truly is important to find the best plan for your needs, regardless of the carrier. If you would like, one of our agents would be more than happy to help you find a plan that will cover your drug for the lowest possible cost. Complete this form to get started.

    1. Bob, yes, according to their website, Cimzia is covered now covered by Medicare Part B. However, it is recommended to confirm this with your physician before receiving the injection.

  4. I missed the original time period to sign-up for supplement or medi gap plans. I am 49. I am on cimzia now it’s under Part B 513.00 a month coinsurance with advantage plan. My question is if I move too another state am I still not eligible for medi gap plans until 65 Desperate to lower my cost.

    1. Samantha, if you move out of your Medicare Advantage plan service area, you will qualify for a Special Enrollment Period. This would make you eligible for a Medicare Supplement. However, not all states are required to provide Medigap coverage to those under age 65. You can review the list of states here.

      1. Moving out of your service area does not create an SEP for enrollment in a Medicare supplement, because there are no enrollment periods for Medicare supplements, only for Medicare advantage, or prescription coverage.

      2. Brandon, when you move out of your Medicare Advantage service area, you are given an SEP to enroll in Part D and guaranteed issue rights to enroll in a Medicare Supplement plan.

  5. 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.

  6. 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.

  7. 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.

  8. 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

  9. 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.

  10. 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.

  11. 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.

  12. 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

  13. 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.

  14. 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!

  15. 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.

    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.

  16. 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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