Does Medicare Cover Remicade?

Medicare recipients who have Medicare Part B or a Medicare Advantage plan have coverage for Remicade infusions if they meet the qualifications.

Remicade and other brands of the drug infliximab are administered as intravenous infusions by a physician or other qualified health care provider when you visit them in their office, medical facility, or as an outpatient in a hospital setting. Because this type of drug isn’t self-administered, Medicare Part B covers a portion of the cost.

Typically Medicare Part B pays 80 percent of the final approved cost of prescription drugs that are administered in the doctor’s office. You are responsible for the remaining 20 percent as well as your annual Part B deductible. Medicare recipients with Part C coverage are guaranteed, at minimum, all benefits included in Original Medicare Parts A and B. Most Medicare Advantage plans also have extra benefits and additional coverage included.

However, most Medicare Advantage plans require that enrollees visit health care providers that are in the plan’s set network of providers. Depending on your plan, you might not get coverage if you use a physician who isn’t in the plan’s network. Make sure you check with your plan provider before making an appointment for treatment.

To qualify for this benefit, your health care provider, who accepts Medicare assignment, must certify that this specific treatment is medically necessary for you. Also, the medical facility, hospital, or doctor’s office where you receive treatment must accept Medicare assignment. 

How much do Remicade infusions cost without Medicare benefits?

Your physician may prescribe doses of Remicade infusions at different intervals. Typically, the second dose is administered two weeks after the initial dose, and six weeks after the second dose. Then, depending on your medical condition, you may get an infusion every other month or so. 

What you pay out-of-pocket for a single dose of Remicade depends on where you live and who administers it, but it generally costs between $1350.00 and $2600.00 in the U.S.

What is Remicade?

Remicade is one of several brand-name drugs for the chimeric monoclonal antibody biologic drug known as infliximab.

In 1998, the FDA first approved infliximab for the treatment of Crohn’s disease. Since then the FDA has also approved it for the treatment of:

• Ulcerative colitis
• Rheumatoid arthritis
• Ankylosing spondylitis
• Chronic severe psoriasis
• Psoriatic arthritis
• Behcet’s disease

Because chimeric monoclonal antibody biologic might sound like a foreign language, here’s a bit of clarification:

When the body is under attack from a “foreign invader” like a virus or an inflammation, the white blood cells produce antibodies to destroy that invader. These antibodies are produced naturally in healthy humans. 

On the other hand, monoclonal antibodies are man-made in a lab. They are specially designed to target certain foreign invaders just as natural antibodies do. In the case of Remicade, the monoclonal antibodies block the effect of tumor necrosis factor-alpha (TNF-alpha). TNF-alpha is a substance that promotes inflammation and diseases like rheumatoid arthritis.

If your physician has recommended Remicade or another brand-name form of infliximab to treat a condition like rheumatoid arthritis or Crohn’s disease, you might need to know whether your Medicare benefits can help you pay for it.

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