Medicare Coverage for Biologics | Arthritis Information

 

I was wondering if anyone can say (by personal experience) if Medicare now covers Enbrel or the new drug, Simponi?  I know Medicare used to cover only the infusions administed by a professional and not the self-injectables.   Thanks so much!

SharonThat's a good question. It might certainly be a factor in deciding which treatment to have. Does anyone have an answer?
Infusion drugs like remicade are covered under Medicare Part B.

Injectible RA drugs like enbrel would be covered under one's prescription drug plan.

I "think" Medicare Part D, the drug benefit,  covers enbrel, put if you fall into the gap in coverage, the donut hole, one would have to pay the full cost of enbrel, until they "climb out the donut hole," pay out a certain amount (check Medicare website cuz that amount changes each year).  Health care reform may change this though -- if passed one would have to pay 50% of the cost of a brand name drug when in the donut hole.

There are also Medicare Advantage plans, that include a drug benefit.  And I think there are stand alone drug plans.  These may cover enbrel.

I "think" it is open enrollment for Medicare plans until end of December.

I don't have any personal experience regarding this, only know from what I've read and from my cousin who is weighing Medicare supplement plans at this time -- she's asked me to look over the explanation of benefits -- ugh.

You might consider contacting the enbrel makers and ask to speak to someone regarding insurance, they may be able to provide more information.  Good luck.



Joie2009-11-16 15:46:51It is open enrollment in medicare until Dec 31.  The injectables are covered under medicare Part D which is the prescription plan.  All of these meds fall under the specialty tier of the various prescription plans.  I have yet to see one that covers the injectables at anything less than a 33% co pay.  Of course you also fall into the doughnut hole like in Feburary because these meds are so expensive.  When you come out of the doughnut hole you would be responsible for 5% because it is the greater amount. well.. that's lovely. FROM CBS 60 MINUTES, July 29, 2007

"If you have ever wondered why the cost of prescription drugs in the United States are the highest in the world or why it's illegal to import cheaper drugs from Canada or Mexico, you need look no further than the pharmaceutical lobby and its influence in Washington, D.C. . . .

One reason those profits have exceeded Wall Street expectations is the Medicare prescription drug bill. It was passed more than three-and-a-half years ago, but as 60 MinutesSteve Kroft reports, its effects are still reverberating through the halls of Congress, providing a window into how the lobby works. . . .

The unorthodox roll call on one of the most expensive bills ever placed before the House of Representatives began in the middle of the night, long after most people in Washington had switched off C-SPAN and gone to sleep. . . .

"The pharmaceutical lobbyists wrote the bill," says Jones. "The bill was over 1,000 pages. And it got to the members of the House that morning, and we voted for it at about 3 a.m. in the morning," remembers Jones. . . .

The legislation was the cornerstone of Republican's domestic agenda and would extend limited prescription drugs coverage under Medicare . . .

Why was the drug lobby so interested in this bill and what did it have to gain?

. . . It prohibited Medicare and the federal government from using its vast purchasing power to negotiate lower prices directly from the drug companies.

"The key goal was to make sure there'd be no interference in the drug companies' abilities to charge high prices and to continue to increase those prices," says Pollack. correspondent

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<> Honestly, I am not on the payroll for Kaiser! However, with what I have heard on this and other forums, the Kaiser Senior Advantage plan that I have beats anything out there. My monthly premium is , plus the something that Medicare withdraws from my Social Security. I pay for a Remicade infusion. I've had tests up the ying-yang this year and most I pay co-pay or nothing for. I know Kaiser is not available in all areas, but if you are in a coverage area, I would strongly suggest you check it out. Yes, I am in the donut right now, but even at that some of my meds are only through Kaiser. The brand name costs are out of sight in the donut, but they work with us to delay refilling until after the first of the year. The Kaiser docs, pharmacy assistants and pharmacists are all working for the patient! Amazing! Many of the docs have left their private clinics to join Kaiser because they were sick of dealing with the BS insurance reimbursement issues - which I have to deal with as a private social worker! The docs want to be docs and not businessmen/women. I have a great team of doctors who are all connected to each other and to me via my computer records and the internet. During this enrollment period, it makes sense to look at this option. I only share this with you because I have found it so amazing! I was paying for a group Kaiser plan before Medicare and that was 0+ per month. I'm hoping nothing changes under the new government plan!well Mary one of the major targets of all of the current medical plans going through congress are cuts in the medicare advantage program.  They want to cut reimbursements in that program and that will lead to price increases in the program.  So if the reform plans pass you can plan on kissing your Kaiser deal goodbye. Thank you to all of you who responded.  Before going on Medicare, my Enbrel costs were /month; the rest was paid by private insurance.  (At one time I paid only /every 3 months).  Before going on Medicare, I was switched to Orencia.  We have maintained the same private insurance my husband had before retirement.  They now pick up the remaining balance after Medicare.  Even though Orencia has helped me, I just think I could feel better on something else.  This may not be true, as I know my condition is worsening and maybe this is as good as I can feel without adding more drugs.  Anyway, I have to check out what's available in case I do make a change in the future.  Will call our private insurance company this week.  As usual, the information on this board is so helpful.  Thanks again and hope you all have a painless day! Medicare Advantage plans -- privately administered health insurance -- were created in 2003, with the idea that private health insurance companies could deliver health care more cheaply than traditional Medicare.  They don't.  Medicare Advantage plans costs the government (taxpayers) 14% more than traditional Medicare.  With baby boomers retiring and possibly joining MA plans, spending on MA plans would increase. Health care reform would reduce funds to MA.  How private insurance companies would respond is uncertain -- they could become more efficient or they could take less in profits and direct that money to actual health care. One change to traditional Medicare that would save beneficiaries money, would be to close the donut hole and allow  the fed gov to  negotiate for cheaper brand name drugs with the drug makers -- like the fed gov does for the Vets Admin health program.  Joie2009-11-17 10:34:19Medicare Advantage though is truly more reflective of the actual medical costs to seniors and disabled because with the Advantage program  you do not need to purchase a supplemental medigap policy to pay what medicare doesn't.  I would be perfectly willing to buy a reasonably priced medigap policy but unfortunately in the state of Ohio there are none for disabled persons.  Because of my LTD payments and SSDI I receive too much to qualify for medicaid to cover the differences but a medigap policy would push me into banqruptcy...seriously it would have cost me more than my COBRA did and I still would have needed a Part D policy.  I understand the concerns about advantage costing more but any cuts should go back into regular medicare not to a general populace health plan.what is the coverage for enbrel now?  I know I can't even attempt to buy my monthly shots.. I can't  imagine the financial hardship to have to pay alot..... Buckeye - I know the new health care plan is looking at cutting into the benefits for us seniors - not fair, in my humble opinion. I've worked hard to get the benefits I have and do not think it is fair for the government to yank away benefits we have all been counting on all these years. Not a thing I can do about it except gripe. I have not received any information from Kaiser as yet.   As for payments from Medicare for injectables, my doctor knew I was in the donut hole and said the infusions would be cheaper because the injectables like Enbrel fall under prescription drugs at least for Kaiser.
Health care reform would not eliminate Medicare Advantage plans, but reduce MA spending -- cuts would apply to the extra benefits that go beyond traditional Medicare.   
go to the Enbrel Website... they help with co-pays if you are qualified.Hi Joie, nice to see you on here again.  Hope you are doing well Joie and thanks for the info.
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