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Entyvio Medicare Coverage

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Posted 7/11/2024 8:32 PM (GMT -5)
Currently Entyvio is covered under Medicare Part "B" if given by infusion. Now that it is available as a self injection that is not covered by Medicare Part "B" but by the Medicare Part "D" Prescription plan. Has anyone seen information about Infusions no longer being covered since injections are available. This will cause a significant increase in the cost for Seniors on this drug in the USA.
Thanks for any input
Posted 7/11/2024 10:36 PM (GMT -5)
I’m worried about that too!!! I asked my dr if I’d be able to stay on the Infusion instead of the pen and he said of course. But that was before the pens were actually available. And probably without knowing what rules Medicare is going to come up with. 🤞🤞🤞

I think a $2000 cap on out of pocket for medications is supposed to happen in the next couple years? That would make a big difference — as long as there’s no loophole about it only applying to covered medications and they decide to not cover entyvio.
Posted 7/11/2024 10:51 PM (GMT -5)
I'm worried too. That was supposed to be my next drug if Remicade ever stopped working.... And since I had PG the doctors have said I can't do the abdomen shots. I have to have the infusion. (I don't understand why...the needle breaks the skin going in wherever it goes in regardless of short or infusion)

Please let me know what you find out.

Clo
Posted 7/12/2024 8:48 AM (GMT -5)
I do not want to do the pen. I’m needle phobic and I don’t like pain. I did give myself monthly injections for a couple of years for my migraines. But they only had a small amount of med in them and I still had to steel myself to do that one. Took only maybe 15 seconds of actual injecting and that was about all I could tolerate. I imagine the pens have a larger amount of liquid to inject and take longer and are probable every 2 weeks?

I don’t mind my infusions at all. Only 30 minutes every 8 weeks. I’ve gone to the same facility with the same nurses for 7 years and always have a nice visit.
Posted 7/26/2024 1:57 PM (GMT -5)
For those who are concerned about Medicare changing its Part B coverage for Entyvio delivered by pump. It is true that the meds taken by injection (without the use of a pump) will not be covered by Part B. . However, the good news is that starting 2025, there will be a ceiling of $2,000 total for covered meds. under part D. Additionally that dreaded "donut hole" will be with us no longer.
Posted 7/26/2024 11:01 PM (GMT -5)
I think the key words for the cap are “covered meds”. I can see them not covering expensive meds so we’re still screwed.
Posted 7/28/2024 12:16 PM (GMT -5)
Everyone....

My infusion clinic called me. July 1st new rules went thru regarding Medicare coverage on expensive medications. Medicare reduced the amount they were willing to pay for Remicade so my infusion clinic will no longer take patients with Medicare as primary. The amount is too low and secondary insurance payments are based upon the Medicare approved amount so secondary insurance can not "absorb" the amount Medicare is now refusing to pay.

I've been looking for a new infusion clinic but so far many of the ones I've called are doing the same thing as my clinic, not accepting new patients, or not doing Remicade at all. They have also indicated they are doing the same with other medications.... But I didn't ask anything after the Remicade. I was just too panic stricken.

So you might want to call and ensure everything is ok before your next infusion.

Clo
Posted 7/29/2024 11:04 AM (GMT -5)
Thats horriible news Im on entyvio which its starting to fail me Dr wants me to go on remicade Im on medicare hopefully we can go to a hospital these drugs are to expensive
Posted 7/30/2024 10:45 AM (GMT -5)
This makes me so worried!

I would assume a hospital has to go ahead no matter the coverage??? My infusions are done at a hospital owned outpatient clinic.
Posted 7/30/2024 1:13 PM (GMT -5)
I feel so bad for all of you who may loose coverage because of Medicare. I'm in Canada and so far not effected. I couldn't continue with IV Entyvio if I was not covered. I prefer the IV as eventually I could go back to the 8 week schedule.
Sassy 😹
Posted 7/31/2024 11:55 AM (GMT -5)
Sassy...i agree, it's heartbreaking.
The threat is here with the possibility of national Pharmacare 😕. Let's hope it never happens.

q
Posted 8/3/2024 10:10 AM (GMT -5)
I’ve gotten several medications for free by applying to the medication manufacturer’s program. The problem is it’s a process to do the application, then get the dr to fill out their section and prescription, then slog through them going through her insurance to make sure the price is not affordable for you. Then you have to reapply each January.

Still worth it in the long run, but initially you’d need about a month (unless they have a streamlined process in our case because of the timing of infusions) which might result in a delay to getting an infusion on time. Or injection, as the case may be — injections would be even more problematic in timing since they are scheduled in shorter time spans than infusions.
Posted 8/19/2024 8:11 PM (GMT -5)
just saw a commercial with the Entyvio pen medicare wont cover the Pen
Posted 8/20/2024 6:05 PM (GMT -5)
Well, I think I've found an infusion clinic. They are working with me to ensure it's covered.... But they took are rethinking Medicare patients. It's the Medicare amount reimbursed for the drug itself. If this falls thru I will have to go to a hospital to obtain it.... But I'm afraid that's going to cost me a fortune.

I'm so frustrated. It looking like I'm going to be a little late with my infusion... But the stress has caused a mini flare.

So I'm still watching what Medicare is doing on the prescriptions side. My prescription is thru BCBS.... Not Medicare. But does the prescriptions count towards your max out of pocket?

Clo
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