Remicade copay w/Medicare? | Arthritis Information

Share
 

Please someone answer for me! My RD just ordered me to start Remicade infusions on 11-12. I have the original Medicare and Medco.

All I can find is that it is 20% copay! If this is correct, there is NO WAY I can afford this. What good is Insurance if you have a copay over 00?


Help please!

Hi, did you talk to the billing dept. at the infusion center.  They'll have some answers for you.  I'm on Medicare along with my other insurance and I know that my drugs come out of the prescription part of the plan.  Also check with Medicare because there may be some special provisions for Remicade.  Let us know what you find out.  LindyYikes! Are you in an area served by Kaiser? I'm not sure how it works to get on their Senior Advantage Plan but that's what I have. I was on Kaiser through a group before I turned 65 and just transferred over to Senior Advantage when I was Medicare eligible. You don't want to hear what I pay for a premium (it's so low!). When I go in for my Remicade infusion, I have to pay my regular co-pay, which is . You might want to look on the Kaiser site and see if they serve your area. I'd flip out if my co-pay was ,000! Good luck.P. S. My Remicade does not come out of the prescriptions but out of treatment. My rheumy told me it would be cheaper to have Remicade for that reason - the other biologics are prescriptions and I'm in the Medicare gap right now so would have to pay a lot. 
Remicade, because it is an infusion drug, is billed under Medicare Part B, not the drug benefit Medicare Part D.

Do you have a Medigap plan, a Medicare supplemental plan?  I think that might cover the 20% not covered by Part B.

I think there is another person on this site that takes remicade and is on Medicare, and she can probably be more helpful.

RA drugs are expensive.  There are many private plans that do not cover them at all, and private and government plans that cover a percentage of the total cost, which still leaves the insuree with a substantial portion to pay.

You might consider calling the makers of remicade.  They generally have someone to help with insurance related questions.  Here is their website and phone number.  Good luck.

Thanks all. I was looking into switching to a Senior advantage plan as well. I know it is not covered under regular prescriptions because it has to be administered at an infusion site.
I have tried every site and help program out there and they all say with insurance, they will not help.
I might just cancel it until I can get on better insurance.  My RD is insistant on the Remicade because I am still early in the stages and my wrists/hands are showing signs of nodules already even with all the other stuff I take.
I never realized the regular Medicare was so chinzy! Why did I work and pay in for over 35 years? GrammaKathy2009-10-26 16:22:57

If you use am infusion center that accepts Medicare payment in full then you can't be billed for the balance.  That's why you need to talk to the billing dept. at the infusion center.  You may not have to pay 20%.  That's one of the safety factors built into the Medicare program.  Lindy

Medicare Supplemental Coverage
Most patients that have Medicare also have some type of secondary insurance coverage. This secondary coverage may be an employer-sponsored plan, Medigap plan, or Medicaid program. These plans offer a wide variety of supplemental coverage to Medicare. For example, Medigap plans may cover some or all of a patient's 20 percent co-insurance and deductible for administration of REMICADE provided through Medicare Part B. However, Medigap plans typically do not provide this type of coverage for REMICADE if it is provided under the Part D prescription drug benefit.



So...it is 20% copay. Boy, that sucks! Thanks for the link Joie!
GK,

You might want to consider posting over on the Arthritis Foundation RA website too for other people's experiences.  A member there mentioned he was on Medicare and remicade.  If I recall correctly, the infusion was administered in the doctor's ofc and the doctor may have accepted the Medicare payment as full payment. 

Also, consider Lindys suggestion and contact the infusion center.  Folks on AF mentioned different costs depending if the infusion drug was administered in a hospital, infusion center or a doctor's office.

Good luck with your investigating -- hope you find an affordable means to take remicade.  Take care.

   
GrammaKathy, when you call and talk to the Remicade people, see if they have assistance on the co-pay or pay a portion.  My RD is great in finding assistance and she has told me several of the drug companies will pay co-pays from 6 months to a year.

Best to you, I hope you find a solution quick as well as the relief you deserve!

Often, assistance from pharmaceutical houses is not available to Medicare recipients. It is a sad fact of life that being on any governmental insurance, even state aid, limits sources of assistance for paying for the very drugs that are less than affordable on government run insurance programs.

Kathy, I send my best wishes for a quick resolution of your dilemma. Shug

edited for inability to spell and type all at once.
Spelunker2009-10-27 08:03:50My infusion was done in a department of the cancer center so my office visit co pay was all I needed to pay which was 25 dollarsMedicare recipiants are not elgible for most assistance programs. Regular medicare the part B copay is 20%.  Unfortunately the copay for most Medicare Advantage policies is also 20% however with the Advantage program there is a maximum out of pocket limit which regular Medicare does not have.
Again unfortunately Medigap policies for people on disability (not old age ) can be exorbinant especially in those states that don't require that any company selling medigap policies must offer them to all medicare elgible persons.  In Ohio out of 70 odd companies selling medigap policies only 2 (both with huge lists of BBB complaints) sell to people below the age of 65.  Those policies cost around ,000 and that was before buying a Part D policy as well. 
I chose a Medicare Advantage policy...it was cheaper even if I do have to come up with 00 for medical expenses. 
Drugs to treat RA, like the biologics -- remicade, enbrel and humira  -- are very expensive.  The Medicare Modernization Act of 2003, which established Medicare Part D, the drug benefit, prohibited the federal government from negotiating directly with pharmaceutical companies for lower prescription drug prices.

The Veteran's Affairs health program can negotiate for lower prices, and, thus many brand name drugs are cheaper.  A member on the Arthritis Foundation site, wrote the RA drug humira, would cost him ,000 a month through his private insurance but only a month through the VA.

The link below is to a 2007 article about the passage of the MMA of 2003 and some questionable tactics used to get it passed.  Congressman Billy Tauzin, a key player in pushing through this legislation, is currently the President of PhRMA, the lobbying group for the drug industry.

Those that support legislation that would allow the federal government to negotiate for lower drug prices for the Medicare program, should contact their U.S. representatives and senators.

 Joie2009-10-27 10:45:28My RD's nurse and their patient advocate? (I think) are working on it. I will probably end up on one of the others that I can do myself. It really sucks because my RD is EXCELLENT. He really knows what he is doing. In the last 3 months, my RA has gone from mild/moderate to moderate/severe. I believe I have nodules starting to form as well. My wrists hurt so bad I can hardly turn them at all; especially my left. (I'm a lefty)

Well, I guess whatever happens will happen. It really sucks that this happens because we can't afford the treatment we need.  :(

PS I am under 65 and on disability.
GK,
 
This is from the REMICADE website:
 
http://www.remicade.com/remicade/global/getting_support/insurance_information.html
 

Is REMICADE Covered by Insurance?

Therapy with REMICADE for ulcerative colitis, Crohn’s disease, ankylosing spondylitis, psoriatic arthritis, plaque psoriasis and rheumatoid arthritis is covered by most insurance plans, including commercial insurers, Medicare, and Medicaid. Coverage policies may vary by insurer, by individual, or even between plans offered by the same insurer. If you have any questions about insurance coverage or reimbursement, you should first call your insurance company or Medicare. If you have questions or concerns, or if you need additional information related to medical coverage for REMICADE, you may call AccessOne® at 1-888-ACCESS-1 (222-3771) for free assistance.

Your benefits may vary depending on:

Medicare: Medicare Carriers and Fiscal Intermediaries (claims processors) for all states cover infusions of REMICADE in doctors' offices and hospital outpatient facilities. The traditional Medicare Fee-For-Service Program does not cover infusions of REMICADE when provided by home infusion companies or retail pharmacies.

Medicaid: Medicaid also covers infusions of REMICADE, but coverage may be restricted to certain treatment settings or may require precertification. You should contact your insurance company or call AccessOne® at 1-888-ACCESS-1 (222-3771) for help in meeting any precertification requirements.

Managed Care Plans: Most managed care plans such as Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs) cover therapy with REMICADE. Managed care plans typically require some cost sharing by you for infusion therapies. However, these plans are likely to require precertification and completion of referral forms for specialist care, and may limit the choice of providers from whom you may obtain treatment.

Traditional Health Insurance: These plans usually cover therapy with REMICADE. Typically, this insurance offers coverage for a wider range of services, but with a higher level of copayment than a managed care organization. Precertification or prior authorization usually is not required. To find out if your insurance benefits cover REMICADE, call your insurer directly or contact AccessOne® at 1-888-ACCESS-1 (222-3771).

In addition to obtaining insurance information, it might also be helpful to locate condition-specific support groups and resources.

levlarry2009-10-30 08:05:38 [QUOTE=GrammaKathy] My RD's nurse and their patient advocate? (I think) are working on it. I will probably end up on one of the others that I can do myself. It really sucks because my RD is EXCELLENT. He really knows what he is doing. In the last 3 months, my RA has gone from mild/moderate to moderate/severe. I believe I have nodules starting to form as well. My wrists hurt so bad I can hardly turn them at all; especially my left. (I'm a lefty)Well, I guess whatever happens will happen. It really sucks that this happens because we can't afford the treatment we need.  :(PS I am under 65 and on disability.



[/QUOTE]


I'm confused. You say that your RD is excellent. He really knows what he is doing. Then you say..in the last three months, my RA has gone from mild to severe. Sounds like your RD is not doing such an excellent job. Just an observation.
Lor,

I "think" GK may have been expressing her frustration in not being able to go onto Remicade, her doc's recommendation, because of insurance issues.

GK,

Below is a link to an article, "Your Medicare Options."  You might want to give it a look.  Within the article are also other links to helpful sites. 

I have used the "State Health Insurance Assistance Program" in understanding and selecting Medicare plan options for my Mom and found them to be very helpful.  They cannot recommend one plan over another, but can help understand coverage and terms, and help compare options.

Good luck.

<> Normal 0 false false false MicrosoftInternetExplorer4 <>

In Medicare Part A you will be automatically covered for certain services that will help maintain your overall health These types of services will help you certain illnesses that could be passed around.

Medicare Part A covered Medicare patients providing some preventive services to issues like:

Cardiovascular screenings

Diabetes screening

Flu shots

Glaucoma tests



Gramma K, I have Medicare and AARP and they pay everything.  I do go to a hospital to have the infusion.  I had BCBS before, but AARP is much better and cheaper. 
I am doing well on the Remicade!

Copyright ArthritisInsight.com