Does Medicare Cover Reclast?
In the United States, there are over 10 million people older than 50 who have been diagnosed with osteoporosis. While most of them are women, approximately two million are men. In addition, there are over 43 million people who currently have low bone mass levels and an increased risk for osteoporosis.
Osteoporosis is a condition that causes bones to become brittle, weak, and more prone to fractures. It can happen if your body doesn’t create new bone tissue fast enough to replace the old tissue.
There are usually no symptoms of osteoporosis in the early stages, but as the condition progresses, you might begin to experience the following signs:
- A gradual loss of height
- Bent posture
- Back pain due to issues with vertebrae
- Bone fractures
The most common factors that contribute to osteoporosis are inadequate nutrition and a lack of physical activity, but heredity and your personal history of bone fractures can also raise your risk.
If you entered menopause at an early age, you have taken corticosteroids for a prolonged period in your life, or you have a parent who’s had a hip fracture, you should let your health care provider know. You might be a good candidate for prescription medications like Reclast, which is used to treat or prevent osteoporosis in these situations.
How does Medicare cover Reclast?
Reclast, also known as zoledronate, is a prescription medication used to deter bone loss and help prevent fractures. It is typically prescribed for the treatment of osteoporosis that is due to menopause or the use of steroids in people with a high risk of bone fractures.
If your physician believes you’re a candidate for treatment with Reclast and certifies that it’s medically necessary, Original Medicare Part A (hospital insurance) or Part B (medical insurance), may cover its share of the expenses for the drug and visits by a home health nurse to administer it if you meet the following criteria for eligibility:
- You’re female
- Your physician certifies that you have a bone fracture due to postmenopausal osteoporosis
- Your physician also certifies that you, or any family member or caregiver can’t administer the drug
- You’re eligible for Medicare Part B and home health care services
Medicare Part B pays for 80 percent of the final approved costs for the drug. You pay 20 percent after covering your Part B deductible for the year. Medicare pays 100 percent of the cost for a home health nurse to administer the drug in your home.
How does Medicare Advantage help cover Reclast?
If you have a Medicare Advantage (Part C) plan, your provider must cover at least all the benefits included in Original Medicare Parts A and B. Depending on the type of Medicare Advantage plan you are enrolled in, you might be required to use certain health care providers and medical facilities to be eligible for coverage. Your out-of-pocket costs also depend on your individual plan coverage. If you aren’t sure about restrictions or allowances regarding your coverage, you should ask a plan representative before making health care appointments.
What are the eligibility requirements for home health care services?
You may be eligible for home health care coverage if you meet all the following conditions:
- You’re in the care of a physician who’s created a care plan for you and is reviewing it regularly.
- Your physician certifies that you need any of the following: Intermittent skilled nursing care aside from taking blood samples; physical, speech-language pathology, or occupational therapy services when you meet certain conditions.
- Your physician certifies that you are homebound.
If you require more than part-time or intermittent skilled nursing care, you aren’t eligible for home health care coverage through Original Medicare Part B.