Does Medicare Cover Zilretta? Your Comprehensive Guide

If you’ve got ongoing knee pain and Zilretta is on your radar, you’re probably asking, “Does Medicare cover Zilretta?” The short answer is yes, Medicare can cover Zilretta, but it’s not as simple as showing up and getting the shot.

senior with knee pain being examined by a doctor with a nurse taking notes - does medicare cover zilretta

There are certain rules and steps you have to follow for Medicare to foot the bill. Stick around, because we’re going to break down what you need to know to get Medicare to cover your Zilretta treatment.

In this article, you’ll discover:

The conditions you need to meet for Medicare to pay for Zilretta
How Medicare Part B and Part C deal with Zilretta costs in their own ways
What amount might come out of your own pocket
Additional options to make Zilretta more affordable for you

Does Medicare Cover Zilretta?

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, also known as Medicare Part C, offer coverage for Zilretta just like Original Medicare does. However, it’s important to note that the specifics of the coverage can vary between different Medicare Advantage plans.

This means that while Zilretta is generally covered, the exact details—like how much you’ll need to pay out-of-pocket—may differ from plan to plan. Therefore, it’s advisable to consult with your individual plan’s guidelines or customer service to understand the full scope of what is covered and what financial responsibilities you may have.

How Much Does Zilretta Cost?

The average price for a 32 mg Zilretta shot is about $630. Keep in mind that this price can change depending on where you live or where you get the shot. So, for the most up-to-date cost, it’s a good idea to check with local healthcare providers or pharmacies.

Out-of-Pocket Costs and Considerations

How Much Will You Pay?

How much you’ll end up paying for your Zilretta shot can depend on several factors. These include the type of Medicare plan you have, whether you’ve met your deductible for the year, and if you have any coinsurance to deal with. In most cases, once you’ve met your deductible, Medicare Part B will cover 80% of the cost. That leaves you to cover the remaining 20%.

To give you an idea, if the average cost of a Zilretta shot is around $630, your 20% share would be about $126. However, if you have additional Medicare coverage, like a Supplement Plan, that could pick up the leftover 20%, lowering your out-of-pocket cost to zero. Without any extra coverage, you’d be looking at that $126 bill each time you get a Zilretta shot.

The “Donut Hole” and High-Cost Drugs

Medicare Part B has something known as a “donut hole,” which is a gap in coverage. What this means is if you spend a certain amount of money on medications in one year, any costs above that limit will have to come straight out of your pocket.

Given that Zilretta isn’t cheap, getting this shot multiple times in a year could push you into this coverage gap, making you responsible for the full cost.

However, there’s some hope. There’s a program called Extra Help that could assist you in covering these costs, but you’ll have to meet certain conditions to qualify. So, if you find yourself in the donut hole because of getting Zilretta shots, it might be worth looking into the Extra Help program to see if it can ease some of that financial burden.

Help for Paying Drug Costs

The Extra Help program is designed to help folks who don’t make a lot of money with the cost of their medications. You’ll have to show that you meet some money-related rules to get this kind of help. But Extra Help isn’t the only option; some states and even the companies that make the drugs have programs that could help you pay for Zilretta.

If the cost of Zilretta is stressing you out, don’t keep it to yourself. Talk to your doctor and reach out to your Medicare plan. They can give you advice on how to manage the costs and may be able to point you toward programs that can help make Zilretta more affordable for you.

Other Cost Factors to Remember

The cost of a Zilretta shot can vary quite a bit. For example, if you’re on a Medicare Advantage plan or live far from a big city, you might find that Zilretta is more expensive. But there’s a flip side: you could possibly save some money if you get your Zilretta from a specialty pharmacy that focuses on certain kinds of medications.

Before you decide to go ahead with Zilretta, it’s a really good idea to have a chat with your doctor. They can fill you in on the benefits and downsides of the treatment, and also give you an idea of how much it’s going to cost you. That way, you can make a well-informed decision that takes both your health and your finances into account.

Does Private Insurance Cover Zilretta?

Many private health insurance plans do cover Zilretta, although there are some that don’t. Typically, you’ll be covered if your doctor says you need Zilretta for your medical condition and writes you a prescription. Sometimes your insurance will want a go-ahead from your doctor before they’ll cover the cost; that’s called “prior approval.”

The money you’ll need to pay yourself can vary. It might be a set fee, known as a copay, or a part of the total cost. If you’re not sure what your plan covers, the best thing to do is talk to your insurance company or ask your doctor for advice.

Keep in mind, some insurance plans might only cover Zilretta for certain age groups, or they might want you to try other treatments first. Also, insurance plans can change what they cover from one year to the next, so make sure to check if you’re still covered when it’s time to get more Zilretta. To really understand the costs and what’s covered, it’s a good idea to talk things over with your doctor.

Understanding Zilretta: What is it?

What is Zilretta?

Zilretta is a medication your doctor can prescribe to help with knee pain caused by a condition called osteoarthritis. It’s a shot that goes right into your knee and can help you feel better for as long as six months.

What’s in Zilretta and How Does it Work?

Zilretta has an ingredient called triamcinolone acetonide that helps to lessen swelling. The medicine is made to release this ingredient slowly, giving you relief from knee pain that lasts for a longer time.

Why is Zilretta Important for Knee Pain?

Osteoarthritis is a common problem that can make your joints ache and even make simple movements tough. It’s the type of arthritis that most people have. Zilretta can help you with your day-to-day activities by reducing the knee pain caused by osteoarthritis, and its effects can last for up to six months.

What are the Benefits and Risks of Zilretta?

The upsides of Zilretta are that it can give you pain relief that lasts a long time and can help you move better. It generally has fewer side effects than similar medications you would take by mouth. However, it’s not all good news. Some people might feel pain, see redness, or have swelling where the shot was given. Other side effects you might experience include headaches, feeling sick to your stomach, and a higher risk of getting an infection.

Conclusion

In a nutshell, we answered the big question: Will Medicare help pay for your Zilretta shots to ease your knee arthritis pain? We went through how Medicare Parts B and C work, what you might have to pay yourself, and pointed out some special programs that could help lower those costs for you.

Why does this all matter? Because understanding your medical bills shouldn’t make your knee pain even worse. Knowing your options lets you talk more openly with your doctor and make decisions that are good for both your health and your wallet.

So, what’s your next step? If what you read here was useful, consider sharing it with friends or family who are dealing with similar problems. And if you have something to add, go ahead and leave a comment. Your feedback helps us create even more useful information for you.

Frequently Asked Questions

How much is a Zilretta shot?

The cost for a Zilretta shot to help with knee pain is around $678 for a single dose. Keep in mind, this price can vary depending on where you get the shot. This is the price you’d pay if you’re covering the cost yourself, without any insurance.

Does Medicare cover knee injections?

Yes, Medicare does cover knee shots like hyaluronan injections that have FDA approval, but there are specific guidelines. First, you’ll need x-rays to confirm you have knee osteoarthritis. If your doctor recommends it, Medicare will chip in for the cost of one knee shot every six months. Just remember, you’ll have to cover the yearly Part B deductible before Medicare starts helping with the costs.

How many times can you get a Zilretta shot?

ZILRETTA is made up of small particles that gradually release medicine into your knee. This helps control pain for a period of around 4 to 6 months.

How often does Medicare cover Zilretta?

If your doctor recommends a knee shot and you have Medicare, you’re in luck. Medicare will cover one shot every 6 months.

How long does a Zilretta injection last?

The effects of Zilretta injections can last for as long as 4 – 6 months. During clinical trials the medication was found to result in a significant reduction in knee pain for 3 months. The data found 70% of those in the trial experienced either no knee pain, or mild knee pain 3 months after their injection.

Does Zilretta make you gain weight?

Weight gain is listed as a potential side effect of taking Zilretta. But it is listed as a less common side effect of this drug because it’s not clear how frequently this side effect will occur. If it does cause weight gain, it may be due to the drug making you hungrier and/or fluid retention.

How long does it take for Zilretta to start working?

Zilretta usually starts to make a difference about a week after the injection. In contrast, a regular hydrocortisone shot can start working much faster, sometimes in just a few days or even a few hours.

Is Zilretta just for knees?

Zilretta is a type of knee injection designed to help people with knee arthritis manage their pain. It’s meant only for the knee, not for smaller joints like those in the hand.

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.