Does Medicare Cover Zilretta?

One common health condition that many seniors develop is osteoarthritis in their joints. There are various treatments for osteoarthritis, including an injectable suspension called Zilretta.

If this is a treatment your doctors is recommending and you are looking into, you may be wondering “does Medicare cover Zilretta?” In this article, we answer that question in clear, plain English. You will also find the average costs of Zilretta if you have to pay out of pocket for it.

The short answer is yes. Medicare will cover the cost of Zilretta. But not 100% of the time. As is often the case with Medicare, certain conditions have to be met in order for Medicare to pay for your Zilretta. 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 Zilretta. Medicare provides coverage for your Zilretta if it is considered medically necessary. Your healthcare provider must first order the treatment for Original Medicare to provide coverage. Coverage for Zilretta is provided by Medicare Part B.

Medicare Part B provides coverage for your hyaluronic acid injections. But it must first be medically necessary to treat a condition such as osteoarthritis. For Medicare Part B to provide coverage, you will also need to undergo an X-Ray to show that you have osteoarthritis.

Also, the healthcare provider who prescribed the drug and the pharmacy where you will buy it must accept Medicare assignment. It must also be given as part of your healthcare provider’s service. However, Medicare Part B will only provide coverage for Zilretta if a licensed medical professional administers it. Medicare Part B will not provide coverage if you will administer the drug yourself.

Once approved by Medicare Part B, they will provide coverage for one hyaluronic acid injection every six months.

Medicare Part B also includes coverage for other types of knee gel injections for osteoarthritis. Part B provides coverage for corticosteroid injections and placental tissue matrix injections under the same conditions for hyaluronic acid injections.

Once approved, Medicare Part B covers 80 percent of the costs of your Zelretta. You will pay for the remaining 20 percent as a copayment or coinsurance.

Part C Coverage for Zilretta

Medicare Advantage plans (Medicare Part C) also provide coverage for Zilretta. This is because Advantage plans are required to cover the same treatments and services as Original Medicare covers. Coverage will differ between the plans, however. So you will need to check with your plan to see exactly what it covers and how much the out-of-pocket costs are.

How Much Does Zilretta Cost?

The average price of a 32 mg Zilretta intra-articular powder for injection, the extended-release cost is $630. However, the exact cost of Zilretta may vary depending on where you live or where you buy the medication.

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.