Arthritis is a common problem among seniors. Rheumatoid arthritis, however, is an often debilitating condition marked by pain and loss of joint function. It often affects the hands and wrists, which complicates daily life. While rheumatoid arthritis can’t be cured, there are a number of prescription medications that can help treat it. One of the available treatments is Orencia, which is often administered by infusions. For someone seeking relief, you’d want to know if your Medicare coverage includes Orencia infusions.
What Is Rheumatoid Arthritis?
Rheumatoid arthritis or RA is a chronic, degenerative condition that affects the joints. While the cause or causes remain uncertain, the immune system starts treating your joints like an invading disease. This leads to swollen and painful joints. The condition can damage cartilage and the bones around joints. Other possible symptoms include:
• inflammation around the lungs and heart
• weight loss
• carpal tunnel syndrome
• peripheral neuropathy
Common treatments include NSAIDs, lifestyle changes, and disease-modifying antirheumatic drugs (DMARDs).
What is Orencia?
Orencia is a prescription medication used in RA treatment. The medication works by interfering with a signal process that activates T cells, one of the major cells in your body’s immune response. Orencia is typically used as second-line treatment. That means that doctors turn to it when another standard course of treatment, such as DMARDs like methotrexate, don’t show good results. In cases where the RA shows rapid progression, doctors use it as a first-line treatment. Since Orencia acts as an immuno-suppressor, infections are a common side-effect of treatment. Orencia comes as either a shot or intravenous infusion.
Does Medicare Cover Orencia Infusions?
Medicare coverage for Orencia infusions is still a gray area. Orencia infusions are administered by medical professionals in an outpatient setting. So, Part B might cover the treatment. However, Part B doesn’t specifically cover Orencia. Some Medicare Advantage plans do cover Orencia infusions specifically. Orencia also appears on some Part D formularies so you may get coverage that way.
Since Orencia infusions are a very expensive treatment, it’s not practical for most patients to pay for it out of pocket. The direct cost of an Orencia infusion, at present, is $3327 per infusion. If Medicare provides coverage, your costs will vary by what part of Medicare provides coverage and how they structure their formularies. You should have a long discussion with your doctor and your Medicare Advantage or Part D provider about coverage before you begin treatment with Orencia.
Rheumatoid arthritis is a degenerative condition that happens when your immune system gets confused and starts attacking your joints. While it can’t be cured at present, Orencia infusions are one possible treatment for it. The issue of Medicare coverage remains somewhat murky. Orencia infusions might be covered under Part B, Part D or a Medicare Advantage plan. Given the very high per-infusion cost, you should discuss coverage with your doctor and Part D or Advantage plan provider before you begin treatment with Orencia infusions.
Medicare Part D: Medicare Prescription Drug Coverage