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Does Medicare Cover Nucala?

Does Medicare Cover Nucala? Get the Scoop Here

If you’re asking, “Does Medicare cover Nucala?” you’re probably dealing with something like severe asthma and looking for a bit of financial relief. 

doctor and patient discussing does Medicare cover Nucala in the doctor's office
Doctor and patient discussing Medicare’s Nucala coverage

The short answer to the question is yes. Medicare can help cover the cost of Nucala, but there are some rules you’ve got to follow. Stick around, because this article will lay it all out for you.

You can find a lot more information on the treatments, services and conditions Medicare covers in our article, What Does Medicare Cover?

Below, you’ll learn:

  • The specific rules or conditions you need to meet for Medicare to pick up the tab on Nucala
  • How much you’ll probably still have to pay yourself
  • How different kinds of Medicare plans, like Part C and Part D, come into play
  • Other ways to get financial help if you need it
  • Alternative medications to consider if you can’t get coverage

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

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

Senior in a doctor's office reading about Medicare coverage for Nucala and other medications
Senior reading brochure about Medicare coverage for medications

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 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.

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. 

Cost Implications for Medicare Beneficiaries Who Need Nucala

Medicare Part D has different rules for sharing the cost of drugs like Nucala. Usually, Nucala falls under Tier 5, which could mean you pay more. How much you pay varies based on your specific Medicare plan. 

Copayment: This is a set amount you pay each time you refill your prescription. If your copayment for Nucala is $50, you’ll pay $50 for each refill.

Coinsurance: This is a percentage of the drug’s price that you pay. If you have a 20% coinsurance for Nucala, you pay 20% of each refill’s cost, while Medicare covers the rest.

Deductible: This is the money you must spend before your Medicare plan starts to help. If you have a $400 deductible for Nucala, you’ll pay the first $400 before Medicare kicks in.

There’s also a “donut hole” in Medicare Part D, a gap in coverage where you pay the full price of the drug. Nucala is expensive, so you might hit this gap quickly and could end up paying a lot.

To manage these costs, you can:

  • Pick a plan with low copayments or coinsurance for Nucala.
  • Join a plan that has a copay assistance program to help lower costs.
  • See if you qualify for a discount from Nucala’s maker, AstraZeneca.
  • Consider using a mail-order pharmacy for cheaper rates.
  • Talk to your doctor about less expensive treatment options.

How Much Does Nucala Cost? 

The cost of a single 100mg/ml autoinjector of Nucala is $6,100. This cost is unlikely to vary greatly.

Alternative Assistance Programs for Nucala

Nucala is prescribed for conditions like severe asthma and eosinophilic granulomatosis with polyangiitis (EGPA). While effective for these conditions, the cost can be a concern. However, various financial assistance options are available to help offset the expense.

If you’re worried about the cost of Nucala, there’s some good news. GSK, the company behind the medication, offers various programs to make it more affordable. They have options like the NUCALA Co-pay Program, the Bridge to NUCALA Program, and even a Patient Assistance Program

And don’t forget, there are other ways to get financial help too—you can search online or chat with a social worker or financial counselor for more information.

In addition to federal assistance, some states offer their own programs to make medications more affordable. For more details on what’s available in your area, it’s a good idea to contact your state’s Medicaid office or health department.

Lastly, organizations such as the Cystic Fibrosis Foundation and the American Lung Association provide support and resources.

If the cost of Nucala is a concern, consulting with a healthcare provider or financial advisor to explore these options is advisable.

What is Nucala?

Nucala is a drug designed to treat severe asthma that’s linked with high amounts of a specific white blood cell called eosinophils. It’s also used for a rare condition involving inflammation, known as EGPA. The way Nucala works is by blocking a certain protein that controls these white blood cells.

Overview of Nucala: Uses and Advantages

Nucala is an additional treatment option for individuals aged 6 and older with asthma characterized by high eosinophil levels. The medication aims to lower these eosinophil levels and improve asthma management.

It is also prescribed for adults with a condition called EGPA, with the intent to reduce inflammation and alleviate symptoms.

Significance of Nucala for Patients with Specific Conditions

If you’re dealing with severe asthma and high levels of eosinophils, a type of white blood cell, Nucala can be a game-changer for managing your symptoms. Not only does it help you breathe easier, but it also lowers the chances of having a severe asthma attack.

For people with a specific condition called EGPA, Nucala is also helpful in calming down inflammation and easing symptoms, making a big difference in how you feel day-to-day.

Alternative Treatments to Nucala

Xolair (omalizumab) is a medicine used to treat allergic asthma and chronic hives. It helps by stopping a certain protein in your body that reacts to allergens. 

Cinqair (reslizumab) is another medicine for severe asthma. It targets a specific protein that helps create a kind of white blood cell involved in inflammation. 

Fasenra (benralizumab) is a newer medicine also for severe asthma. It works by finding and eliminating certain white blood cells that contribute to inflammation.

Dupixent (dupilumab) is used for skin conditions like atopic dermatitis, as well as asthma and some sinus issues. It blocks the action of two proteins that are linked to inflammation.

Summing It Up

In summary, if you’re dealing with serious lung issues like severe asthma or EGPA, it’s really important to know how Medicare covers Nucala. We’ve covered the nitty-gritty details like what conditions must be met for Medicare to pay for it, what you might have to pay out of your own pocket, and how coverage can differ between Medicare plans. Knowing all this can make it easier for you to work your way through the healthcare maze and find extra financial help or even other treatment options.

Why should you care about all this? Because dealing with long-term health issues like severe asthma or EGPA can really weigh on you, both emotionally and in your wallet. Knowing the ins and outs of Medicare’s rules for covering Nucala helps you make smarter choices about your healthcare, potentially saving you money in the long run.

We’re really interested in hearing what you think about Medicare and Nucala. Got something to say? Drop a comment below. And if you think this article could help someone you know, go ahead and share it with them.

Frequently Asked Questions

What is the generic version of Nucala?

The medication Nucala is technically called mepolizumab, but currently, no generic version is available.

Is Nucala covered under Medicare Part B?

Yes, Medicare Part B can help pay for Nucala if you get it as an outpatient. But there are some rules you need to follow, detailed above.

What does Nucala cost if you don’t have insurance?

The price for one Nucala autoinjector with 100mg/ml is $6,100. This price is usually pretty stable and doesn’t change much.

Will Medicare cover asthma inhalers?

Medicare generally covers asthma inhalers if they are prescribed by a physician. The coverage is mainly provided through Medicare Part D, which is the prescription drug component. However, inhalers considered experimental or not yet approved by the FDA are typically not covered.

Will Medicare pay for biologics?

Medicare Part B helps pay for some medicines called biologics, which treat conditions like arthritis, skin problems, bowel issues, and multiple sclerosis. But it doesn’t cover all these medicines, and there might be some rules on what it will pay for.

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

Also, you can check out other articles in this series including, does Medicare cover ice machines and Medicare coverage for wart removal.

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Medicare Plan Tips Team

Annie Kaye is a writer and researcher who was thrown into the Medicare world while taking care of her ailing mother. Even with a degree in Library Science and a long history of fighting for what's right, she felt lost. She learned a lot about Medicare during that time and now writes to help others understand how the system works.