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Carol Eustice

Rheumatoid Arthritis Patients on Infusible Biologics Need to Follow Medicare Reimbursement

By November 19, 2013

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IVIn June 2013, it was announced that infusible biologic drugs (e.g., Simponi Aria, Orencia) used to treat rheumatoid arthritis would not be covered by Medicare Part B. The reason: the drugs were classified as being "usually self-administered" and placed on a Self-Administered Drug (SAD) list. After reconsideration, Medicare has decided to exclude Orencia and Simponi Aria from the SAD list and place them on a Self-Administered Drug Exclusion list -- once again providing reimbursement for the two drugs. It was decided that the drugs are "not usually self-administered", after all. Confused yet? It gets worse.

I started Simponi Aria in August. I had full assurance from the Simponi representative who deals with my doctor that Medicare covers it. We asked him about it, to be sure we all were on the same page.  You know, no surprises. Four weeks later, I had my second infusion, with the third to follow 8 weeks after that. I received a Medicare summary in the meantime. Neither treatment was covered, and as you know, it carries a hefty price tag. My doctor has not been reimbursed for treatment #1 or treatment #2. If you look up this mess on the Internet, the information provided indicates it should now be covered -- but while Medicare was playing "is it or isn't it", they didn't pay out. My doctor didn't order the medication for tomorrow's treatment. Why would he and who can blame him? Seriously, I don't blame him. I'll be going in to discuss my options.

Other than to let a little steam escape, I wrote this to forewarn you. If you are treated with infusible biologic drugs for rheumatoid arthritis -- pay close attention to your billing statements and Medicare summaries. This may or may not affect you.

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Photo by Robert Byron (iStockphoto)

November 21, 2013 at 5:30 pm
(1) Lorie says:

Just one more thing to worry about or rather “Another”…So sorry that you are going through this…~hugs~

December 26, 2013 at 12:17 am
(2) tim says:

medicare is a nightmare

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