Hi RA Team: I've been on Medicare and had a supplement - BC/BS for the past few years. I've been thru the regiment of the biologics - Humira, Enbrel, Rituxan, Remicade, Orencia, Xeljanz ..... now I'm on Simponi which is "covered" at a reduced rate at a Tier 5 level. However, come Jan. of 2017, it will no longer be a covered RX :( I've been on just about every other biologic available. Any suggestions on a Medicare supplement that actually covers high-deductible biologics? Or are all the Plans… read more
I have Anthem Bluecross/Blue shield and our policy just renewed. Are they straight denying the medicine now? Last December my rheumatologist wanted to put me on Xeljanz injections and that was denied by Blue Cross/Blue Shield. Instead I had to take one of their preferred medicines and fail for at least six months before I could get the Xeljanz. So, I am on Simponi, which is very costly and I have to use a sick day every two months for the infusion instead of injecting myself. Maybe you can get your medicine covered if you"fail" their preferred drug.
Medicare.gov had some suggestions. Make sure to hold Anthem accountable for following your policy guidelines, they tried to deny my Otrexup prescription last year without following the notification procedure. Here is what I found on Medicare.gov
A drug in a lower tier will generally cost you less than a drug in a higher tier. In some cases, if your drug is on a higher tier and your prescriber thinks you need that drug instead of a similar drug on a lower tier, you or your prescriber can ask your plan for an exception to get a lower copayment.
A Medicare drug plan can make some changes to its formulary during the year within guidelines set by Medicare. If the change involves a drug you’re currently taking, your plan must do one of these:
Provide written notice to you at least 60 days prior to the date the change becomes effective.
At the time you request a refill, provide written notice of the change and a 60-day supply of the drug under the same plan rules as before the change.
I'm 56, on Medicare because of disability and get Orencia infusion once a month. I also pay for a.supplemental insurance (United Healthcare plan F ) which is an additional $322/month and also have BCBS for prescription coverage. The Orencia is 100℅ covered each month between Medicare and UHC. I think it covers most bialogics. You might want to check it out. It's well worth the money!
Check and see if the pill Xeljenz is covered, good luck and all the best ☃️
We never share your personal information with anyone.