Orencia and Medicare, need help! | Arthritis Information


Hi everyone I am new to these forums, this is my first post! Glad I found this, hoping to find helpful information and friends here.  My husband is 55 and has had RA now for a couple years. He is now on Orencia (since October), and it is finally showing him improvement.  He tried Enbrel, but it did nothing for him so he went right to Orencia.   He was a general contractor and had his own business then had to give it up because of RA, and went through the long process to get on disability.  I had to quit my home business and go back to work full time outside the home so we could get better health insurance.  Medicare kicks in August 1st for him, and so we have to switch him to a Medicare health plan.  The problem is I have conflicting information on how Orencia is covered with Medicare.  It is considered a Tier 4 drug, and with the gap and everything in the Part D, we're looking at the 00+ out of pocket then (5%?) -- I am still trying to figure all this out, but it sounds like medicare won't cover much of it.  BUT I have also heard that if you have the infusion done at a hospital rather than in the rheumatologist's office, that it will cover more. 

I'm hoping someone out there has information on this that can help us make a decision on what to do.  We live in Washington State and we're considering the Asuris medicare advantage plan. 
Any advice appreciated...  thank you! Have you talked to your husband's RD office.  They deal with Medicare on a daily basis and will be able to give you guidance.  It's a lot to wade through.  Have you talked with Medicare?  LindyI've been told by Medicare that they cover more in the hospital than in docs office.  That is correct.
this might help you until you gets things right with medicare.
Thank you. Yes we have talked to his doctor's billing office and they aren't much help.  Thank you for the info, if anyone out there has Medicare and has Orencia infusions I would love to hear from you about how Medicare covers it.  Also, is it true Medicare is not able to "adjust" medicine costs and other costs down? 

I am on Orencia and Medicare.  Medicare pays all of my IV treatment cost except the co-pay for my part D supplemental insurance.  I have the IV at my docs office administered by RN's who work at our local hospital. 

I have also had the yearly osteoporosis IV at the hosp and paid nothing.
I have medicare and used to take Remicade.   Since it was something done on an outpatient basis it was covered 80% under Medicare for me but I still had to come up with the other 20% on my own.  The rest I managed to get taken care of by a charity program that the hospital has.  You might want to look into if your hospital has anything like this and qualifications for patient participation.  
Hope this helps a little.
Bob H.

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