Does Medicare Cover Orencia Infusions?

Arthritis is one of the leading causes of work disability in the United States, according to the Centers for Disease Control and Prevention. Rheumatoid arthritis (RA), a disease that occurs when the immune system attacks the joints, is one of its most debilitating forms. In addition to causing joint pain and fatigue, the condition can damage the skin, eyes, lungs, circulatory system, nerves and kidneys.

Orencia infusions are approved by the Food and Drug Administration to treat moderate to severe RA symptoms and to reduce the risk of complications associated with the disease. If your doctor has prescribed Orencia, Medicare may cover some of the cost of the drug.

Does Medicare Cover Orencia Infusions?

Medicare Parts A, B and D may cover Orencia under specific circumstances. Whether the drug is covered depends on where the infusions occur and what type of plan you have. Your doctor should be able to advise you as to whether Medicare Parts A or B will cover your infusions. People enrolled in Original Medicare can also call 1-800-MEDICARE for coverage information. If you have a Medicare Advantage plan, you'll need to contact your insurance provider.

What Is Orencia?

Orencia is a prescription medication used to treat moderate to severe symptoms of rheumatoid arthritis in adults aged 18 and over. RA-related pain and swelling occur when the immune system activates T-cells that give rise to inflammation. The drug interrupts this process by preventing the activation of T-cells. Clinical trials showed that Orencia may lower the risk of future permanent damage to the bones, joints and other tissues in the body.

What Forms of Orencia Are Available?

Orencia is now available in three forms:

• Intravenous infusions given monthly in a doctor's office
• Prefilled ClickJet Autoinjectors used weekly at home
• Prefilled syringes used weekly at home

What Is the Generic for Orencia?

The generic name for Orencia is abatacept. 

How Much Does Orencia Infusion Cost?

Drugs.com and GoodRx are both sources where you can check prices for Orencia infusion and pre-filled Orencia syringes. 

When Does Medicare Part A Cover Orencia?

Medicare Part A may pay for Orencia infusions that take place during a covered stay in a hospital or long-term care facility. You will likely have to satisfy your deductible before coverage begins, and you may be responsible for coinsurance depending on how long your stay is.

When Does Medicare Part B Cover Orencia?

Generally, Medicare Part B covers the cost of intravenous infusions performed in a doctor's office, provided that the treatment is deemed medically necessary and the physician participates in Medicare. You will usually have to first pay your deductible to receive coverage. Once your deductible is satisfied, Medicare Part B typically pays for 80% of the cost, leaving you responsible for the remaining 20%. A Medicare Supplement or Medigap plan may help you pay all or some of what you owe.

When Do Medicare Advantage Plans Cover Orencia?

Medicare Advantage plans or Medicare Part C must cover anything that Medicare Parts A and B do. As a result, the plans are likely to cover infusions that take place in a hospital or in a doctor's office. Some plans may require you to choose a doctor in your plan's network.

When Does Medicare Part D Cover Orencia?

If your doctor prescribes self-administered Orencia injections, coverage for the drug falls under Medicare Part D. Insurers are required to provide coverage treatments for rheumatoid arthritis; however, plans can choose which specific drugs to cover. Almost half of Medicare drug plans surveyed by GoodRx covered Orencia. 

What Tier Is Orencia?

Medicare Part D plans establish drug tiers that determine how much you pay out of pocket for your medications. Orencia usually falls under Tiers 3 or 4, which correspond with brand name medications. Tier 3 is the drug your plan specifies as the preferred treatment. Generally, your share of the cost is less with Tier 3 than Tier 4 drugs.

How Much Will I Pay for Orencia With Medicare Part D?

If your plan covers Orencia, the amount you'll pay out of pocket changes during the four stages of coverage. 

• Deducible stage: You'll pay the full price of the drug.
• Post-deductible stage: You'll likely have to pay a copay that will vary by plan.
• Donut hole stage: You'll typically be responsible for 25% of the cost.
• Catastrophic coverage stage: Your plan will typically pay for the entire cost of the drug.

What Are Alternatives to Orencia?

Orencia is classified as a biologic agent. The Mayo Clinic reports that doctors may prescribe other biologic agents for RA, such as:

• Adalimumab (brand name Humira)
• Anakinra (brand name Kineret)
• Certolizumab (brand name Cimzia)
• Etanercept (brand name Enbrel)
• Golimumab (brand name Simponi)
• Infliximab (brand name Remicade)
• Rituximab (brand name Rituxan)
• Sarilumab (brand name Kevzara)
• Tocilizumab (brand name Actemra)

Other classes of drugs may also be used to treat rheumatoid arthritis, including:

• Corticosteroids like prednisone
• Disease-modifying antirheumatic drugs (DMARDs) like methotrexate and leflunomide
• Targeted synthetic DMARDs like tofacitinib and upadacitinib

Your doctor will decide which treatment for rheumatoid arthritis is likely to be most beneficial for you.