How much does Medicare pay for Remicade infusions?

In this article:

• How Medicare covers prescription drugs
• Does Medicare cover Remicade infusions?
• What is the cost of Remicade infusions on Medicare?
• How to save on Remicade infusions

In this article

• How Medicare covers prescription drugs
• Does Medicare cover Remicade infusions?
• What is the cost of Remicade infusions on Medicare?
• How to save on Remicade infusions

Remicade (infliximab) is a prescription medication that is effective at treating several autoimmune inflammatory health conditions. It is given by a healthcare professional through an intravenous infusion (infusion into a vein) over a period of about two hours. It can reduce the symptoms of Crohn’s disease and ulcerative colitis in adults and children 6 years and older. It also treats rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and plaque psoriasis.

Remicade is a tumor necrosis factor (TNF) blocker. It blocks the action of the tumor necrosis factor-alpha (TNF-alpha) protein that is linked to inflammation in the body.

“Remicade was approved in 1998 for treatment of Crohn’s disease and colitis, and it is still one of our most effective treatments,” says Raymond Cross, MD, a board-certified gastroenterologist at Mercy Medical Center in Baltimore.

Although the drug is expensive without insurance, it is typically covered by Medicare Part B.

How Medicare covers prescription drugs

You can get Medicare coverage for prescription drugs in one of several ways. The most common way for those who already have Medicare Parts A and B is to enroll in a Medicare Part D plan, either when initially enrolling in Medicare or during Open Enrollment. The other way is to enroll in a Medicare Advantage (Part C) plan—a plan that’s offered by a private company approved by Medicare and typically includes Parts A, B, and D—prescription drug coverage.  

Every Medicare drug plan has a list of covered drugs known as a formulary. Formularies vary by plan, but in all cases, drugs are assigned certain levels called “tiers.” The drugs in a particular tier each have a different cost, and lower-tier drugs typically cost less than drugs in higher tiers. 

Does Medicare cover Remicade infusions?

Remicade is different from most prescription drugs because it needs to be administered at a healthcare provider’s office or in an outpatient hospital setting. For that reason, Medicare Part D won’t typically cover Remicade, but Medicare Part B might. However, beneficiaries are still responsible for the Part B deductible, copays, and coinsurance associated with Remicade treatment. In most cases, beneficiaries will pay up to 20% of the Medicare-approved amount for Remicade after they meet their deductible, but the total amount can change as the drug’s price changes. 

Although Medicare Part B may cover Remicade in an outpatient setting, it doesn’t typically cover it for people who receive it from home healthcare providers.  

Medicare may require prior authorization, also called precertification, for Remicade since it is a specialty drug. In this case, your healthcare provider may be required to explain why you need it before Medicare will consider covering it. 

What is the cost of Remicade infusions on Medicare?

Without insurance, Remicade could cost between $4,000 and $7,000 per dose. “It is hard to say how much it costs on Medicare as so many factors come into play,” says Selly Vazquez, an insurance expert in Brookfield, Connecticut. Ultimately, it depends on your coverage details, where you live, the cost of the drug, and your prescribed dosage. Consult your Medicare provider for an idea of what your portion of the shared costs for Remicade will be. 

“If the insurance company declines to pay for Remicade, it may pay for another similar product,” Dr. Cross explains. These similar products are called biosimilar medicines, which are similar to the brand-name biologic drug but tend to cost less. The biosimilars that your healthcare provider may consider as an alternative to Remicade infusions include Avsola (infliximab-axxq), Inflectra (infliximab-dyyb), and Renflexis (infliximab-abda). “Despite the differences in names, biosimilars are just as effective. Monitoring during treatment is identical, and the safety is the same,” Dr. Cross says.

How to save on Remicade infusions

Remicade can be expensive, but for people with certain autoimmune inflammatory conditions, it may be an important part of their treatment plan. If you can’t afford Remicade, start by speaking with your healthcare provider about your options. They often know ways to make it more affordable while taking your treatment plan into account. 

State assistance

Medicare Savings Programs or Medicaid may be able to help you pay for Medicare Part A and Part B expenses as well, including deductibles, coinsurance, and copayments. You can apply for Medicare Savings Programs or Medicaid through your state of residence.