Does Medicare Cover Orencia Infusions? 

For over one and a half million people in the United States, rheumatoid arthritis is a condition they live with daily. Rheumatoid arthritis is an autoimmune disease that attacks the cells lining the joints. It’s a progressive and chronic disease that has no cure. Fortunately, there are prescription medications that help control symptoms like pain, stiffness, and swelling. And treatment for rheumatoid arthritis can help stop the progression of damage to joints, cartilage, and bone. 

These days, many health care providers prescribe Orencia infusions for their patients living with rheumatoid arthritis and other autoimmune conditions. Orencia infusions help alleviate the symptoms of rheumatoid arthritis and help mitigate joint and bone damage. Orencia is a recombinant DNA-generated fusion protein that your physician can inject subcutaneously or through an IV. 

Typically, Orencia is an expensive drug, so having Medicare coverage to help with the cost is important for beneficiaries. Here’s how you can get Medicare coverage for Orencia infusions and injections.  

Does your Medicare coverage help pay for Orencia? 

If you have Original Medicare Part B (medical insurance), you may have coverage for Orencia infusions. To be eligible, your health care provider must certify the infusions are medically necessary for the treatment of your condition and the infusions can’t be self-administered. You must also get your infusions from a licensed medical provider who accepts Medicare assignment. It must be administered at a medical facility that also accepts Medicare assignment. 

In this instance, Original Medicare Part B pays for 80 percent of the final approved cost for the administration of the Orencia infusions. You are responsible for the remaining 20 percent of the cost for the administration and the drugs. You must also have covered your Part B annual deductible.

Coverage for Orencia injections

If your health care provider prescribes Orencia as a self-administered subcutaneous injection, Original Medicare Part B doesn’t cover it. For this form of Orencia, you can get your coverage through a stand-alone Medicare Part D prescription drug plan, or from a Medicare Advantage (Part C) plan that includes prescription drug coverage.  

To get coverage for the subcutaneous injectable form of Orencia, your prescription drug plan must include its coverage on its drug formulary. The formulary is the list of drugs that a plan covers. The amount you pay out-of-pocket for your prescription depends on how your plan categorizes the drug. Most Medicare-affiliated prescription drug plans classify Orencia as a Tier three or Tier four drug. Generally speaking, Tier four drugs carry a copayment that is 10 percent of the drug’s cost. 

How much does Orencia cost without Medicare insurance coverage? 

Prices for Orencia vary depending on where you live, where you shop, what the dosage is, and how it is administered. On average in this country, one 250 mg packet of intravenous powder for infusion costs about $1,300.00. And a one-month supply of pre-filled syringes of Orencia can cost up to $7,000.00 or more. 

If you aren’t sure whether your Medicare prescription drug plan covers Orencia injections, check the plan’s printed formulary, check their official website, or call them and speak with a licensed representative. 

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