Immunosuppressive drugs reduce the risk of organ rejection.
They’re also used to manage autoimmune and inflammatory conditions.
If you have end-stage renal disease (ESRD), Medicare will cover the partial cost of these drugs, even if you’re under 65.
If you have Medicare because of ESRD, your medications will be covered for the first 36 months after a kidney transplant.
Starting in January of 2023, lifetime coverage of immunosuppressive drugs may be possible for kidney transplant patients.
Immunosuppressive drugs tamp down the immune system so your body won’t reject a donor organ, such as a heart, lung or kidney. If you need immunosuppressive drugs due to a transplant, Medicare Part B typically will help cover the cost.
They’re also used to control the effects of autoimmune conditions. In this case, Part D coverage may apply.
If you get an organ transplant, you’ll need to be on immunosuppressants for the rest of your life. Without insurance, these medications can cost $10,000 to $14,000 or more annually, a break-the-bank sum for many people.
If you’re eligible for Medicare, you can have coverage for these life-saving medications. Your coverage may vary, based upon certain circumstances.
In this article we’ll talk about the various parts of Medicare and when they pay for immunosuppressive medications.
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Immunosuppressive drugs are covered by Medicare for various medical reasons, such as:
- To stop the body from rejecting donor organs
- To treat autoimmune conditions, such as:
- Multiple sclerosis
- Rheumatoid arthritis
- Crohn’s disease
- Alopecia areata
There are several types of immunosuppressive drugs. Some are taken orally, and others are given via infusion or injection. You may need to take one or more every day.
Medicare Part A coverage
If you are in the hospital for a donor organ, Part A will cover the cost of immunosuppressants you are given during your transplant. These powerful anti-rejection medications are known as induction drugs.
Medicare Part B coverage
Medicare Part B is the part of Original Medicare that covers outpatient services. Part B covers immunosuppressive drugs differently for different populations of Medicare beneficiaries:
If you have Medicare because you have end-stage renal disease (ESRD)
If you qualify for Medicare only because you have ESRD, Medicare Part B will cover the cost of immunosuppressive drugs after you get a kidney transplant. This coverage will end 36 months after you leave the hospital. To ensure eligibility, your procedure must take place at a Medicare-approved facility.
If you have Medicare because of age or disability
If you qualify for Medicare due to age or disability, Part B will cover the cost of immunosuppressive medications for the rest of your life, provided these criteria are met:
- You had an organ transplant.
- You had Part A at the time of the procedure.
- The transplant was done at a Medicare-approved facility.
Medicare Advantage coverage
Medicare Advantage (Part C) plans must cover at least as much as Original Medicare (Part A and Part B). If you have a Medicare Advantage plan, it will cover immunosuppressive medications after an organ transplant, provided you meet the eligibility requirements established by Medicare Parts A and B.
You may also need to meet certain requirements as outlined by your plan. These may include:
- Preauthorization by the plan.
- Confirmation by an in-network, Medicare-approved doctor of a specific diagnosis, prior to transplant.
If you use immunosuppressive drugs to treat an autoimmune condition, the prescription drug portion of your Medicare Advantage plan will cover their cost, provided it includes a Part D benefit.
Part D coverage
Medicare Part D is prescription drug coverage. It is not automatically included in Original Medicare and needs to be purchased as a separate plan.
Every Part D prescription drug plan has a formulary that includes immunosuppressive drug coverage. The specific medications included and their cost will vary from plan to plan.
Medicare only pays for prescriptions filled at a Medicare-approved pharmacy.
Part D covers the cost of immunosuppressive medication prescribed to treat an autoimmune condition. It also covers the cost of medications for medical reasons that warrant their need temporarily, such as having a severe respiratory infection, or COVID-19.
If you didn’t have Medicare Part A at the time you received an organ transplant, it is Part D and not Part B that will cover the cost of immunosuppressive medications. In some instances, these drugs may cost more under Part D than they would under Part B.
If you have ESRD-related Medicare, it will cover the cost of anti-rejection (immunosuppressive) drugs for 36 months after the hospital stay for your kidney transplant ends.
According to the National Kidney Foundation, Medicare coverage of immunosuppressive drugs after a kidney transplant is expanding to lifetime coverage, starting January 1, 2023. These are the requirements they list as qualifications for lifetime drug coverage:
- The kidney transplant was done in a Medicare-approved facility.
- You were eligible for Medicare and applied for this coverage, prior to the transplant taking place.
- You do not receive Medicaid.
- If you have other health insurance, it doesn’t offer an immunosuppressive drug benefit.
If you have already had a kidney transplant and your current Medicare coverage expires before January 1, 2023, you can re-enroll in Part B to begin again at that time. In this instance, Part B will only cover the cost of your immunosuppressive medications. It will not cover any other healthcare costs you may incur. To be eligible to re-enroll, you cannot have current healthcare coverage for immunosuppressants.
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The amount Medicare pays towards immunosuppressive drugs may vary, based upon which part of Medicare is the payer.
If you have coverage under Part A during a hospital stay, it will cover the cost of anti-rejection drugs. Based on the length of your stay, you may have other out-of-pocket expenses.
If you have coverage under Part B, Medicare will cover 80 percent of the Medicare-approved cost of your medications, after the annual Part B deductible has been met.
If you have coverage under Part D, the portion that Medicare pays will be determined by your plan’s formulary.
If you have prescription drug coverage under Part C, your plan will determine the copay you’re responsible for.