Call to speak to a Licensed Insurance Agent
Asthma is one of the most common diseases, affecting over 260 million people worldwide.
Fortunately, there are a number of treatments available to help those who have this disease. One of which is Nucala, a monoclonal antibody that doctors use to treat severe asthma.
If you or a loved one suffer from asthma and this drug could help, you likely have the common question, “does Medicare cover Nucala?” In this article, we answer that question in clear, plain English.
You will also find the average costs of Nucala for those who have to pay out-of-pocket for this drug.
Does Medicare Cover Nucala?
The short answer is yes; Medicare will cover the cost of Nucala. But not 100% of the time. As is often the case with Medicare, certain conditions have to be met for Medicare to pay for your Nucala. Below we look at what these are so you know what to expect.
Original Medicare (Medicare Part A and Part B) provides coverage for Nucala. It provides coverage for your Nucala if it is considered medically necessary. Your healthcare provider must first prescribe Nucala for Original Medicare to provide coverage.
Medicare Part B provides coverage for Nucala in an outpatient setting. However, there are certain conditions that have to be met first. They include:
- You are older than 18 years of age
- You are diagnosed with Eosinophilic Granulomatosis with Polyangiitis or EGPA
- Upon examination, your healthcare provider confirmed that you have a certain level of blood eosinophils
- You have had therapy of concomitant oral corticosteroids for over four weeks
Once approved, Medicare Part B covers 80 percent of the costs of Nucala. You will pay for the remaining 20 percent.
Part C and Part D Coverage for Nucala
Medicare Advantage plans (Medicare Part C) also provide coverage for Nucala. They have to cover everything Original Medicare covers but can offer additional benefits as well. Exactly what each plan covers and how much out-of-pocket costs are depend on the plan.
Medicare Part C plans that include prescription drug plans will also provide coverage for medications your healthcare provider will prescribe to you.
Medicare Part D plans also provide coverage for Nucala. Part D is a prescription drug plan, and just like Medicare Part C, Medicare Part D plans are provided by private insurance companies.
Sixty-four percent of both Medicare Part C and Part D plans provide coverage for the medication Nucala.
Most Medicare plans restrict the amount of purchase for Nucala at a time. If you need to purchase more than the allowed limit, Medicare may not cover the additional amount. In a situation like this, you can either wait until the period has passed before refilling, or you can contact your plan provider and ask for an exception.
Nucala is listed as a Tier 5 drug in the Medicare drug formulary. Tier 5 medications is the most expensive tier in the formulary.
Most Medicare plans also may require you to have prior authorization before they provide coverage for this medication. The usage of this medication has to be for medically necessary purposes. You must contact your plan provider to get authorization.
How Much Does Nucala Cost?
The cost of a single 100mg/ml autoinjector of Nucala costs $6,100. This cost is unlikely to vary greatly.
Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage. Always be sure to double-check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.
Additional Info on Medicare Coverage
This article is part of our series on “What does Medicare cover?”
Also, you can check out other articles in this series, including: Does Medicare cover Sandostatin?