Autoimmune disorders like Crohn’s disease, ulcerative colitis, rheumatoid arthritis, psoriasis, and psoriatic arthritis affect millions of people in the United States, many of whom are over the age of 65.
Symptoms of these autoimmune diseases can be quite uncomfortable and even debilitating. Joint pain, inflammation, severe itching, inflamed and tender skin, as well as diarrhea and cramping are just a few common issues that people with these conditions must live with unless they are treated. If you are diagnosed with one of these autoimmune diseases, your physician may prescribe a drug called infliximab, or the brand-name form of the drug, Remicade.
Remicade is a chimeric monoclonal antibody that is administered through intravenous injections every six or eight weeks. It works by blocking the overproduction of TNF-alpha, which is a protein found in the immune system. When TNF-alpha isn’t under control, it forces the immune system to attack itself causing inflammation.
Does Medicare cover Remicade?
Medicare may cover your prescription of Remicade if a Medicare-affiliated health care provider prescribes it as a medically necessary treatment for a health condition that can be treated by Remicade. Because Remicade is a drug that health care providers must administer through an intravenous infusion, it is covered by Original Medicare Part B rather than Medicare Part D prescription drug plans.
Remicade isn’t a self-administered drug but is typically administered by a licensed medical provider in a doctor’s office or a hospital outpatient setting. However, if you are homebound and you qualify for home health services, Medicare Parts A and B may cover the cost for a home health nurse or nursing aide to administer the drug infusion to you in your home.
Original Medicare Part B (medical insurance) pays 80 percent of the final approved cost of Remicade infusions and their administration. You pay the remaining 20 percent after paying your annual Part B deductible.
Beneficiaries who have coverage through a Medicare Advantage (Part C) plan, may also get coverage for IV infusions of Remicade if they meet the eligibility requirements set by Medicare. Private insurance providers who offer Medicare Advantage insurance plans are required to cover all the benefits provided by Original Medicare Parts A and B, at minimum. Most Medicare Advantage plans also offer extra benefits and additional coverage that Medicare Parts A and B don’t cover.
Depending on the type of Medicare Advantage plan you have, your provider may ask you to use health care providers, medical facilities, hospitals, medical suppliers, and pharmacies that are included in the plan’s network of preferred providers. In some instances, you may not get coverage if you go outside your plan’s network. Check with your plan directly for details if you aren’t sure what your restrictions or allowances are.
How much does Remicade cost without Medicare insurance coverage?
Out-of-pocket costs for Remicade infusions depend on where you live, where you have them done, and who does them for you. As of now, the national average cost of one infusion of Remicade ranges between $5000 and $16,000 without insurance, other assistance, or discounts. These prices are for the drug alone and don’t include the cost of its administration or additional treatments or medications that might be necessary.