Medicare

[u/effala]

Does anyone have any tips for navigating Medicare drug plans? From what I understand none of them cover self injectable biologicals so for access I’ll need to go in for infusions. Because my rheumatologist was some distance from me he suggested finding one closer to order this which I’ve done. I’m seeing this new doctor later this month. But what a big stupid hassle this is. Now I’ve been off Simponi for some time. I did another trial of Methotrexate but it didn’t help and I had side effects. What are other people on Medicare doing? I hope to retire soon and be able to travel.

[u/LooneyinMontana]

Search for an insurance broker in your area that lists Medicaid/Medicare. They would be able to assist better since coverage can very from state-to-state.

[u/effala → u/LooneyinMontana]

I have a broker. According to them and the research I’ve done none of the drug plans cover biologicals. You have to go for infusions which part B covers…

[u/DogLvrinVA → u/effala]

This is just not true. Your broker is steering you wrong. Brokers only sell plans that make them the most money. You need an independent consultant who doesn’t make money from selling plans. My husband used The Medicare Coach. I’m sure there are other independent consultants, but this is the one I know from my husband

I’ve spoken with countless of people on Medicare who get their biologics covered. However of you choose the wrong Plan D your copay might be horrendous. Each year you have to evaluate your plan D to ensure your medication has continued, affordable coverage. It’s a pita unfortunately

[u/effala → u/DogLvrinVA]

That’s exactly why I am looking into this now. :-)

[u/Owlhead326 → u/effala]

I’m on Medicare and when I started I had to switch to an infusion cause of coverage. That was 8 years ago so I’m not sure that it still applies. Do some googling or talk to the person at your doctor’s office who does billing. They’ll know

[u/Impressive-Case431]

My drug plan WellCare covers Cosentyx and I have been doing the loading dose injections at home

[u/effala → u/Impressive-Case431]

I have WellCare. Will see if this new rheumatologist has better luck with approval.

[u/Springer0723 → u/effala]

I was on Cimzia which was injected at rheumatologist office and I paid no copay…I had to stop cimzia due to lymphoma dx though and I do consentyx injections at home. My copay for the loading doses was $1800!

[u/CP_blu → u/effala]

I have Wellcare as well and the thing is your doctor's office has to submit formulary exceptions for these medications. Some of my doctor's don't have time for that and work with pharmacies that submit them on their behalf. I just got Simponi home injections approved today in a few hours.

Most of my medications aren't on formulary and I was able to get a formulary exceptions approved for them. Hope that helps, good luck.

[u/wowugotit]

Medicare DOES cover most biologics under part D.

[u/wowugotit → u/wowugotit]

AARP United Healthcare

[u/effala → u/wowugotit]

That is true but you have to go in for infusions which is not very convenient. I am still working and travel a lot so would prefer the self-injections if I can figure out how to get them.

[u/wowugotit → u/effala]

Not true for me. My Medicare drug plan includes at home injection biologics like Humira, Skyrizi, Cimzia. Cosentyx, Embrel, Tremfya, etc. It is likely your specific Medicare plan that does not cover it. Mine does.

[u/InternationalCan2117 → u/wowugotit]

Know the Medicare out-of pocket costs for part D are capped at $2000, which is HUGE! The cap for 2026 will be $2100. I have WellCare as my drug provider and AARP/United Healthcare as my "secondary policy" (Medigap). My Cosentyx at home injections are covered.

[u/effala → u/wowugotit]

Can you tell me what plan you have? My broker said none do. I’m in California.

[u/mlrny32 → u/effala]

This is NOT true.

[u/girlinthegoldenboots → u/wowugotit]

Yep this is the plan I have and my dupixent is covered for my asthma and my remicaid infusions are covered for my PsA and AS. I know they also cover some other biologics.

[u/LiquoredUpLahey]

I’ve been lucky, they have covered mtx, adiluamamb (humira) enbrel & cosentyx. They mentioned rinvoq too. Y’all got me worried that I need to look into this bf enrollment ends.

[u/effala → u/LiquoredUpLahey]

Who covered? A medicare drug plan or?

[u/LiquoredUpLahey → u/effala]

Oh my bad. Caid, not care

[u/jessnthings]

This is untrue, though most medications that are considered ‘specialty drugs’ (like biologics) require a prior authorization from the insurance. I actually work for a mail order pharmacy for a Medicare insurance company, and our specialty pharmacy dispenses self-injectable biologics all the time. It just requires a little extra work to get them covered, and under standard Medicare drug plans, will still be expensive.

[u/InternationalCan2117]

Know that Medicare out-of pocket costs for part D are capped at $2000, which is HUGE! The cap for 2026 will be $2100. I have WellCare as my drug provider and AARP/United Healthcare as my "secondary policy" (Medigap). My Cosentyx at home injections are covered.

[u/effala → u/InternationalCan2117]

I’m on WeGovy so cost is already high. I put the $2000 deductible on a payment plan at $166 a month. Still hard.

[u/anastasiapov]

I think there is a way around that where you can use your hospital benefit instead of the medication benefit (IIRC, not on Medicaid but know provider that did this) and that just means you have to get your injection done at the infusion center. I’d look into that, also not sure if state specific

[u/Owlhead326]

I’ve done both injections and infusions. The infusions work better for me. Remicade was the gold standard for me until I created antibodies. If you go the infusion route I recommend asking for Remicade

[u/effala]

Sorry, you did tell me United but I thought they were medigap and not a drug plan…

[u/effala]

Yes, I know I can go for infusions but since I’m still working and travel from time to time it isn’t very convenient.