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Many beneficiaries of Medicare receive Xolair to treat symptoms of their asthma. Xolair is also known by its generic name omalizumab.
This medication treats allergic asthma symptoms and chronic hives that have no known cause. It is often prescribed to patients who have tried other treatments for asthma, such as inhalers antihistamine medications, but they have not worked for them.
So a common question many people have is, “Does Medicare cover Xolair Injections?” In this article, we answer that question in clear, plain English. You will also find the average costs of Xolair injections and other helpful info.
Does Medicare Cover Xolair Injections?
The short answer is yes; Medicare will cover the cost of Xolair injections. 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 Xolair injections. Below we look at what these are so you know what to expect.
Original Medicare (Medicare Part A and Part B) provides coverage for Xolair injections costs. Medicare Part A provides coverage for Xolair injections if you get them while you are staying in an inpatient setting such as a hospital or a skilled nursing facility.
Most of the time though, coverage for Xolair injections falls under Medicare Part B. That is because patients will usually get Xolair injections in an outpatient setting such as a physician’s office.
However, for Medicare to provide coverage for your Xolair injections, you will need authorization. To obtain Medicare’s this, you and/or your doctor will have to contact Medicare / your Advantage plan provider. They may require your healthcare provider fill out a document stating why you need the medications.
Medicare Advantage plans (Medicare Part C) also provide coverage for Xolair injections. They cover everything Original Medicare covers as well as offer some additional benefits. However, out-of-pocket costs will vary depending on the specifics of your plan.
Most Medicare Part C plans (around 88 percent of them to be exact) offer coverage for prescription drugs. Medicare Part C plans that offer coverage for prescription drugs are known as Medicare Advantage Prescription Drug Plans (MA-PD).
Medicare Part D also provides coverage for Xolair injections. To find out if your Medicare Part D plan covers Xolair injections, you’ll need to check with your plan provider. They will be able to tell you about coverage and costs for the drug.
At the moment, between 93 and 98 percent of Medicare Part C and Part D plans offer coverage for Xolair injections. Xolair injections are often listed in Tier 5 of Medicare Plans’ Formulary. Medications in Tier 5 in the formulary are often non-preferred brand-name drugs, and they cost more than the medications that are in Tier 1 to 4 in the formulary.
How Much Does Xolair Injections Cost?
A supply of 150 mg of Xolair subcutaneous powder for injection cost around over $1,200. That is the cost if you do not have insurance and were to pay cash for your prescription.
Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage and Medigap plans. 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 weight loss surgeries?