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According to the Centers for Disease Control and Prevention, arthritis is one of the top causes of work disability in the United States.
One of the most debilitating types of the disease is rheumatoid arthritis (RA). RA is an autoimmune disease. In other words, it arises when the immune system attacks the joints.
There are treatments for this condition, and one is a medication called Orencia. If this is a drug that you or a loved one may need, a common question you likely have is “Does Medicare cover Orencia?”
In this article, we answer the question in clear, plain English. You will also find the average costs of Orencia for those who have to pay for it out of pocket.
Does Medicare Cover Orencia?
The short answer is yes. Most of the time, Medicare will cover the cost of Orencia. But this is not true 100% of the time. As is often the case, certain conditions have to be met for Medicare to pay for your Orencia. Below we look at what these are so you know what to expect.
But first, what exactly is Orencia?
What Is Orencia?
Orencia (abatacept) is a prescription medication that is used to treat moderate to severe rheumatoid arthritis or psoriatic arthritis in adults. It is an FDA-approved drug to help those 18 and older reduce the signs and symptoms of RA.
Original Medicare Coverage of Orencia
Original Medicare (Medicare Part A and Part B) provides coverage for Orencia. That is, this plan will cover you only if taking this mediation is considered medically necessary. Your healthcare provider must first prescribe this medication in order for Original Medicare to provide coverage.
When Coverage is Provided by Part A vs. Part B
First, coverage for Orencia is provided by Medicare Part A if it takes place in an inpatient setting.
On the other hand, the administration of Orencia is covered by Medicare Part B if it is given in an outpatient setting.
Once approved, Medicare Part B covers 80 percent of the costs of Orencia. You will pay for the remaining 20 percent.
Medicare Advantage Coverage of Orencia
Medicare Advantage plans (Medicare Part C) also provide coverage for Orencia. All Advantage plans must cover everything Original Medicare covers, but they also offer additional benefits.
Precisely what these additional benefits are and what the costs are for this coverage will depend on your Advantage 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 Coverage of Orencia
Lastly, Medicare Part D, or prescription drug plans, also provide coverage for Orencia. Similar to Medicare Part C, they are provided by private insurance companies.
Fifty-seven percent of Medicare Part C and Part D plans provide coverage for the medication Orencia.
How Much Does Orencia Cost?
Orencia is listed as a tier 5 drug in the Medicare drug formulary. Most of the time, the Medicare drug formulary only has five tiers.
Tier 5 medications are more expensive than Tier 1, 2, 3, and 4 medications.
A carton (4 syringes) of Orencia 125mg/ml costs right around $8,000 on average.
As of now, there are no generic alternatives for this medication.
Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage. Always 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 Hearing Tests?