Does Medicare Cover Orencia Infusions?

Medicare Benefits Solutions
Aug 11, 2021

Rheumatoid arthritis (RA) is a chronic and progressive autoimmune disease that causes the immune system to attack the cells lining the joints. This attack can cause pain, stiffness, and swelling, and as RA progresses, inflammation can cause damage to joints, cartilage, and bone. 

About Rheumatoid Arthritis

Today in the United States, 1.5 million people have RA. Women are three times more likely to get it and are typically diagnosed between the ages of 30 and 60.

While scientists aren’t sure what triggers the immune system to cause RA, you may be at a higher risk if you: 

  • Are female
  • Have a family history of RA
  • Smoke

Many physicians prescribe Orencia to treat symptoms of RA and to help prevent the progression of joint damage. Orencia is a recombinant DNA-generated fusion protein available as either an IV infusion or subcutaneous injection. 

For people living with rheumatoid arthritis, having access to prescription medications like Orencia is life-changing. But for many, the costs are too high. For these reasons, it’s a great relief to have coverage through Medicare benefits. Here’s a look at whether Medicare covers Orencia.

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Does Medicare Cover Orencia Infusions?

If your physician or health care provider suggests that you try Orencia, you can get the medication through intravenous infusions or subcutaneous injections. How you get the drug may affect your coverage.

Coverage with Medicare Part B Benefits

For the infusion, your doctor administers it through an IV into a vein in your arm. You must have this treatment done by your doctor, in an outpatient medical facility, or their office.

In this instance, your Medicare Part B (medical insurance) covers the infusions if your physician certifies that they are medically necessary treatments. Medicare pays for 80 percent of the cost of the medication and the administration if it is done by a health care provider who accepts Medicare assignment. You pay the remaining 20 percent of the cost for the treatment and drug as your copayment. 

Help from Medicare Supplement Insurance

If you have a Medicare Supplement (Medigap) plan, your plan may cover the 20 percent copayment. Medigap plans A, B, C, D, F, G, M, and N pay 100 percent of your Part B coinsurance/copayment. Plan K pays 50 percent and Plan L pays 75 percent of the copayment.  

Coverage with a PDP or Medicare Advantage Plus Prescription Drug Coverage

If you have the subcutaneous injectable form of Orencia, you may have coverage through your Medicare Part D plan (prescription drug coverage) or a Medicare Advantage plan with prescription drug coverage. This depends on whether your plan includes Orencia in its formulary. The amount you pay out-of-pocket depends on your plan’s coinsurance charges.

How Much Does Orencia Cost Without Medicare Benefits?

The list price for Orencia in IV infusion form is $3,685.00 per infusion not including administration costs. The list price for an Orencia injection is $4,851 per month.

If you have prescription drug coverage you will probably pay between $0 and $1,550.00 a month for Orencia depending on the plan you have. Most Medicare beneficiaries pay no more than $25.00 a month for the subcutaneous self-injected drug. 

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