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Has anyone else seen Medicare coverage of biologics go through the roof in 2025?

I am a mostly healthy 77 year old female diagnosed with RA at age 58. I was doing well with Orencia and Plaquenil in the last 2 years. I have a medicare advantage health insurance, the same one for 12 years. My copays have been manageable until this year. I have now stopped the Orencia on the principal that I refuse to pay what they have charged me. I will talk with my provider next week about alternatives to biologics. Any suggestions?

  1. Hi . Do you have a Medicare prescription drug plan? I ask because changes to the plans for 2025 cap out-of-pocket costs at $2,000 and costs can also be spread out over the course of the year. This page from Medicare goes into details on the changes: https://www.medicare.gov/about-us/prescription-drug-law. This article notes that "The annual new cap also includes people with drug plans through Medicare Advantage, which are health plans offered by private insurers:" https://www.cbsnews.com/news/medicare-2000-prescription-drug-cap-january-1-2025-how-it-works. Mind if I ask if you receive your Orencia through infusion or subcutaneous injection? I ask because if you receive it through infusion it might not be covered under the prescription drug changes. Your doctor should be familiar with these changes, as should your provider. I know $2000 isn't pocket change, but I suspect that it is less than what you are talking about over the course of a year. Hope this information is helpful and please feel free to keep us posted on how things are going. Best, Richard (Team Member)

    1. Thank you for your response. I am going to continue on the Orencia through another pharmacy who was willing to explain it all better and is working with me.
      Sincerely
      Sylvia

      1. Hi Sylvia (). So glad you found a professional who is willing to spend some time and work with you! Best, Richard (Team Member)

      2. I am glad to hear that you found a pharmacy that was helpful in explaining and making sure you got the medication you need. Just Keep Swimming....Lynn Marie, Team Member

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