Sunday, November 27, 2022

Is Xeljanz Covered By Medicare

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How Do The Costs Of Xeljanz With And Without Insurance Compare

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The cost of Xeljanz with and without insurance will vary based on a few factors, such as the pharmacy you use. In general, the cost of prescription medications such as Xeljanz is typically higher without insurance coverage than with insurance.

If youd like to know whether youll have a copay with Xeljanz, call your insurance provider. You can also visit this site from Xeljanzs manufacturer to see what costs you may pay if youre prescribed the medication.

What Doses Of Xeljanz Are Available

Xeljanz is available in the following formulations:

  • Xeljanz tablets: 5 mg, 10 mg
  • Xeljanz XR tablets: 11 mg, 22 mg tofacitinib
  • Xeljanz oral solution: 1 mg/mL

Please see the full prescribing information and medication guide for the complete boxed warning. Always speak with a healthcare professional for medical advice or about any changes to your dose so they can monitor and evaluate your condition.

Golimumab For Intravenous Infusion

U.S. Food and Drug Administration -Approved Indications for Simponi Aria

  • Adult patients with moderately to severely active rheumatoid arthritis in combination with methotrexate
  • Active psoriatic arthritis in patients 2 years of age and older
  • Adult patients with active ankylosing spondylitis
  • Active polyarticular juvenile idiopathic arthritis in patients 2 years of age and older

Compendial Uses

  • Oligoarticular juvenile idiopathic arthritis

Intravenous golimumab is available as Simponi Aria and contains the same mechanism of action and labeled black box warning and precautions as subcutaneous golimumab . The most common adverse reactions include upper respiratory tract infection, alanine aminotransferase increased, viral infection, aspartate aminotransferase increased, neutrophil count decreased, bronchitis, hypertension, and rash. Live vaccines should not be given with Simponi Aria.

Intravenous Golimumab for Active Psoriatic Arthritis and Active Ankylosing Spondylitis

Intravenous Golimumab (Simponi Aria for Active Articular Juvenile Idiopathic Arthritis

Intravenous Golimumab for Rheumatoid Arthritis

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Appendix A: Examples Of Contraindications To Methotrexate

  • Clinical diagnosis of alcohol use disorder, alcoholic liver disease or other chronic liver disease
  • Blood dyscrasias
  • Elevated liver transaminases
  • History of intolerance or adverse event
  • Hypersensitivity
  • Interstitial pneumonitis or clinically significant pulmonary fibrosis
  • Pregnancy or currently planning pregnancy
  • Renal impairment
  • Average Costs For Xeljanz With Medicare Drug Coverage1

    Your copay and deductible costs for any prescription drug can vary depending on what coverage stage youre in.

    Deductible stage Typical copay stage
    Your deductible is the amount of money you must spend on covered drugs before your Medicare drug coverage starts paying its share of costs.In the deductible stage, youre responsible for the full cost of your prescription drugs.Some Medicare prescription drug plans have a $0 deductible. Medicare drug plans cannot have a deductible more than $480 in 2022. After you meet your Part D deductible, you enter the initial coverage period.During this phase , you pay a copayment or coinsurance for your covered medications.
    $1,079 $5,153 $1,079 $5,153

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    Unaffordable: Medication Costs At $4800 Per Month With $1000 Copay

    A specialist assisted a caller in their early 60s who is certified disabled and will qualify for Medicare in a few months. The caller is eligible for Medical Assistance for Employed Persons with Disabilities but still wouldnt be able to make ends meet. The individual had been out of medications for several months and could not afford to buy more due to the high cost. Their arthritis medication, Xeljanz, costs $4,800 per month and copays would be over $1,000 each month even after being covered by Medicare. The individual has applied for Extra Help but is waiting to learn if they qualify. In the meantime, this individual does not have needed medications and is at risk for their health deteriorating without them.

    For Medicare Advantage Plans That Do Not Offer Prescription Drug Coverage

    Cimzia, for the indications listed below:

    • Rheumatoid arthritis
    • Is not covered for new starts, unless the member meets ANY of the following:

    • Inadequate response to a trial of Avsola, Remicade, or Simponi Aria
    • Intolerable adverse event to Avsola, Remicade, or Simponi Aria
    • Avsola, Remicade, or Simponi Aria is contraindicated for the member
    • Psoriasis

      Is not covered for new starts, unless the member meets ANY of the following:

    • Inadequate response to a trial of Avsola or Remicade
    • Intolerable adverse event to Avsola or Remicade
    • Avsola or Remicade is contraindicated for the member
    • Crohn’s disease

      Is not covered for new starts, unless the member meets ANY of the following:

    • Inadequate response to a trial of Avsola, Entyvio, or Remicade
    • Intolerable adverse event to Avsola, Entyvio, or Remicade
    • Avsola, Entyvio, or Remicade is contraindicated for the member.

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    Is The Cost Of Xeljanz Less Than That Of Xeljanz Xr

    It depends. The cost of Xeljanz and Xeljanz XR may be affected by factors such as the pharmacy you use and your insurance coverage.

    Its also important to note that Xeljanz and Xeljanz XR come in different strengths. For example, Xeljanz XR is available in an 11-milligram strength, but Xeljanz does not come in this strength. On the other hand, Xeljanz is available in a 10-mg strength, while Xeljanz XR is not. While these strengths seem very similar, your cost could differ depending on whether youre prescribed Xeljanz or Xeljanz XR.

    To learn more about the cost of Xeljanz, talk with your insurance provider or pharmacist. You can also visit this site from Xeljanzs manufacturer to see what costs you may pay if youre prescribed the medication.

    Golimumab For Subcutaneous Injection

    U.S. Food and Drug Administration -Approved Indications for Simponi

    • Moderately to severely active rheumatoid arthritis in combination with methotrexate
    • Active psoriatic arthritis , alone or in combination with methotrexate
    • Active ankylosing spondylitis
    • Moderately to severely active ulcerative colitis who have demonstrated corticosteroid dependance or who have had an inadequate response to or failed to tolerate oral aminosalicylates, oral corticosteroids, azathioprine, or 6-mercaptopurine for inducing and maintaining clinical response, improving endoscopic appearance of the mucosa during induction, inducing clinical remission, and achieving and sustaining clinical remission in induction responders

    Compendial Use for Simponi

    • Axial spondyloarthritis

    Subcutaneous golimumab is available as Simponi , a tumor necrosis factor blocker. Golimumab is a human monoclonal antibody that binds to both the soluble and transmembrane bioactive forms of human TNF. This interaction prevents the binding of TNF to its receptors, thereby inhibiting the biological activity of TNF . Elevated TNF levels in the blood, synovium, and joints have been implicated in the pathophysiology of several chronic inflammatory diseases such as rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis. TNF is an important mediator of the articular inflammation that is characteristic of these diseases .

    Subcutaneous Golimumab for Ankylosing Spondylitis and Axial Spondyloarthritis

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    How Do I Apply For The Xeljanz Patient Assistance Program

    We make it as easy as possible to apply for the Xeljanz patient assistance program. The first step is to complete our enrollment application. Tell us about any medications you are taking, including Xeljanz. We will also ask for details about your healthcare provider, insurance, and your household income. This information is required by the pharmaceutical manufacturers who ship your medication.

    If we determine that you may be eligible for Xeljanz assistance, we will handle the application process for you. We will work directly with your healthcare provider to prepare your application documents. Once we have received the signed application and supporting documents, we will submit them to the patient assistance program on your behalf. Our service continues once you are enrolled in the Xeljanz patient assistance program, and we will automatically request your Xeljanz medication refills for up to 1 year.

    Am I Eligible For The Xeljanz Patient Assistance Program

    We will review your application to determine whether you are eligible for the Xeljanz patient assistance program. Each program has its own eligibility criteria which is set by the pharmaceutical companies, however the factors considered by most programs are:

    • I am a permanent, legal resident of the United States or Puerto Rico
    • I am uninsured or my insurance doesnt cover my medication
    • I meet certain income eligibility requirements

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    Criteria For Initial Approval

    Aetna considers certolizumab pegol medically necessary for the following indications, where the member has a documented negative TB test , an interferon-release assay , or a chest x-ray) within 6 months of initiating therapy for persons who are naive to biologic DMARDs or targeted synthetic DMARDs associated with an increased risk of TB:

  • Moderately to severely active rheumatoid arthritis

  • For members who have previously received a biologic or targeted synthetic DMARD indicated for moderately to severely active rheumatoid arthritis or
  • For treatment of moderately to severely active RA when all of the following criteria are met:

  • Member meets either of the following criteria:

  • Member has been tested for either of the following biomarkers and the test was positive:

  • Rheumatoid factor or
  • Anti-cyclic citrullinated peptide or
  • Member has been tested for all of the following biomarkers:

  • C-reactive protein and/or erythrocyte sedimentation rate and
  • Member meets either of the following criteria:

  • Member has experienced an inadequate response to at least a 3-month trial of methotrexate despite adequate dosing or
  • Member has an intolerance or contraindication to methotrexate
  • Moderate to severe plaque psoriasis or active psoriatic arthritis

    When member meets criteria in or

  • Active ankylosing spondylitis and active axial spondyloarthritis

  • For members who have previously received a biologic indicated for active ankylosing spondylitis or active axial spondyloarthritis or
  • Appendix C: Examples Of Clinical Reasons To Avoid Pharmacologic Treatment With Methotrexate Cyclosporine Or Acitretin

  • Clinical diagnosis of alcohol use disorder, alcoholic liver disease, or other chronic liver disease
  • Cannot be used due to risk of treatment-related toxicity
  • Pregnancy or currently planning pregnancy
  • Significant comorbidity prohibits use of systemic agents
  • Table: Brands of Targeted Immune Modulators and FDA-approved Indications:

    Brand Name

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    For Medicare Advantage Plans That Offer Prescription Drug Coverage

    Simponi Aria, for the indications listed below:

    • Ankylosing spondylitis

      Is not covered for new starts, unless the member meets ANY of the following:

    • Inadequate response to a trial of Enbrel, Humira, or Xeljanz/Xeljanz XR
    • Intolerable adverse event to Enbrel, Humira, or Xeljanz/Xeljanz XR
    • Enbrel, Humira, or Xeljanz/Xeljanz XR is contraindicated for the member
    • Polyarticular juvenile idiopathic arthritis

      Is not covered for new starts, unless the member meets ANY of the following:

    • Inadequate response to a trial of Enbrel, Humira, or Xeljanz
    • Intolerable adverse event to Enbrel, Humira, or Xeljanz
    • Enbrel, Humira, or Xeljanz is contraindicated for the member
    • Psoriatic arthritis

      Is not covered for new starts, unless the member meets ANY of the following:

    • Inadequate response to a trial of Enbrel, Humira, Otezla, Rinvoq, Skyrizi, or Xeljanz/Xeljanz XR
    • Intolerable adverse event to Enbrel, Humira, Otezla, Rinvoq, Skyrizi, or Xeljanz/Xeljanz XR
    • Enbrel, Humira, Otezla, Rinvoq, Skyrizi, or Xeljanz/Xeljanz XR is contraindicated for the member
    • Rheumatoid arthritis

      Is not covered for new starts, unless the member meets ANY of the following:

    • Inadequate response to a trial of Enbrel, Humira, Rinvoq, or Xeljanz/Xeljanz XR
    • Intolerable adverse event to Enbrel, Humira, Rinvoq, or Xeljanz/Xeljanz XR
    • Enbrel, Humira, Rinvoq, or Xeljanz/Xeljanz XR is contraindicated for the member.

    Chemo Treatment At Risk Because Of Plan Mixups

    A specialist received a call from a 63-year-old who was certified disabled and receiving treatments for a cancer diagnosis. She was newly eligible for Medicare. The caller was referred to the Senior LinkAge Line because her pharmacy told her she did not have coverage for her urgently needed medications. Her Medical Assistance coverage was no longer valid for filling her medications once she was on Medicare. She was concerned about a potential lapse in her health care coverage. The caller was also struggling with pneumonia and was unable to fill her prescriptions. She relied on urgent care for nebulizer treatments. After many phone calls to the county and Medicare, the specialist learned that she was not coded on the correct Medical Assistance program, one that worked with her Medicare. The county updated the system so that she could fill her prescriptions and she is now covered under a temporary program until her Part D plan starts in November. She was able to keep her appointment for chemotherapy treatment later that week.

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    Appendix D: Examples Of Conventional Therapy Options For Uc

  • Mild to moderate disease induction of remission:

  • Oral mesalamine , balsalazide, olsalazine
  • Rectal mesalamine
  • Rectal hydrocortisone
  • Alternatives: prednisone, azathioprine, mercaptopurine, sulfasalazine
  • Mild to moderate disease maintenance of remission:

  • Oral mesalamine, balsalazide, olsalazine, rectal mesalamine
  • Alternatives: azathioprine, mercaptopurine, sulfasalazine
  • Severe disease induction of remission:

  • Prednisone, hydrocortisone IV, methylprednisolone IV
  • Alternatives: cyclosporine IV, tacrolimus, sulfasalazine
  • Severe disease maintenance of remission:

  • Azathioprine, mercaptopurine
  • Cost Of Prescription Drugs Creates Hardships For Older Adults

    Specialists with the Minnesota Senior LinkAge Line® talk with thousands of older adults and their caregivers each year. Trellis provides these services in the Twin Cities metro area.

    Our specialists hear heartbreaking stories resulting from the high cost of prescription drugs. These are a few of their stories.

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    Financial And Insurance Assistance

    If you need financial support to pay for Xeljanz, or if you need help understanding your insurance coverage, help is available. For example:

    • There is a Xeljanz savings card available for people with private insurance. You can learn more by calling 844-935-5269 or visiting this site. Keep in mind that if you have government-sponsored insurance, such as Medicare or Medicaid, you wont be eligible for this manufacturer coupon card.
    • A program called the Pfizer Patient Assistance Program is available for Xeljanz. This program provides assistance to qualifying people who have difficulty affording their prescription. For more information and to find out if youre eligible for support, visit the program website.
    • Some websites provide details about drug assistance programs, ways to make the most of your insurance coverage, and links to savings cards and other services. Two such websites are:

    Us Food And Drug Administration

    • Reducing signs and symptoms of Crohns disease and maintaining clinical response in adult patients with moderately to severely active disease who have had an inadequate response to conventional therapy
    • Treatment of adults with moderately to severely active rheumatoid arthritis
    • Treatment of adult patients with active psoriatic arthritis
    • Treatment of adults with active ankylosing spondylitis
    • Treatment of adults with active non-radiographic axial spondyloarthritis with objective signs of inflammation
    • Treatment of adults with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy

    Cimzia carries a Black Box Warning for serious infections and malignancy. These include:

    • Increased risk of serious infections leading to hospitalization or death including tuberculosis , bacterial sepsis, invasive fungal infections , and infections due to other opportunistic pathogens
    • Cimzia should be discontinued if a patient develops a serious infection or sepsis
    • Perform test for latent TB if positive, start treatment for TB prior to starting Cimzia
    • Monitor all patients for active TB during treatment, even if initial latent TB test is negative
    • Lymphoma and other malignancies, some fatal, have been reported in children and adolescent patients treated with TNF blockers, of which Cimzia is a member
    • Cimzia is not indicated for use in pediatric patients.

    Most common adverse reactions include upper respiratory tract infection, rash, and urinary tract infection.

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    Does Xeljanz Xr Cost More Than Xeljanz

    Xeljanz and Xeljanz XR may be prescribed to treat the following conditions in some adults when certain other treatments havent worked to manage symptoms:

    On these sites, you can find insurance information, details on drug assistance programs, and links to savings cards and other services.

    If you have commercial insurance, you may be eligible for the Xeljanz copay savings card. You can learn more by calling 844-935-5269 or by visiting this site.

    If you have questions about how to pay for your prescription, talk with your doctor or pharmacist. Its important to note that if you have government-sponsored insurance, such as Medicare, you wont be eligible for a copay card or manufacturer coupon. But you may qualify for the Pfizer Patient Assistance Program. You may also be eligible for this program if you dont have insurance or cant afford your prescription.

    Xeljanz only comes as a brand-name drug. Its not currently available in a generic version. A generic drug is an exact copy of the active drug in a brand-name medication. But generics tend to cost less.

    Medication Guides For Medicare Eligibles

    The Medication Guides are updated monthly. Links are included below to the Medicare approved Formularies and the most recent updates to the printed version of the Medication Guide for Medicare Eligibles.

    Please have your patient refer to the pharmacy endorsement or rider issued with his or her contract, Evidence of Coverage, member handbook or certificate of coverage to determine whether a particular medication listed is covered. If your patient is unsure about particular coverage/benefits or has questions about the Medication Guide, please have the member call the Customer Service number on his or her ID card. The fact that a particular drug is listed in the guide does not necessarily mean that it is covered under each member’s contract, Evidence of Coverage or certificate of coverage.

    1If you are not sure if your group is a small-group or large-group, please ask your HR administrator.

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    Can Nicerx Help Me Get Xeljanz If I Have Insurance

    We may be able to help you to access Xeljanz patient assistance in a variety of circumstances. This includes when your insurance company will not pay for your Xeljanz medication or if you have a high copay or coinsurance responsibility. We may also be able to help you if you do not have insurance. Please apply online to find out more.

    Ankylosing Spondylitis And Axial Spondyloarthritis

    Spondyloarthritis is a term used to include a group of arthritis-associated conditions. One of the associated conditions include axial spndyloarthritis , which is a potentially disabling inflammatory arthritis that typically affects the spine however, may also affect joints in the arms and legs. Symptoms typically begin before the age of 45. Those with axSpA can be further classified into 2 subtypes such as ankylosing spondylitis and nonradiographic axial spondyloarthritis . Individuals affected by AS exhibit radiographic abnormalities consistent with sacrolitis, whereas, findings are absent or minimal on plain radiography for those with nr-axSpA. Individuals with nr-axSpA may have evidence of active inflammation of the sacroiliac joints on MRI findings . The diagnosis of axSpA, including AS and nr-axSpA, should be considered in persons with continuous chronic back pain prior to age 45, Per UpToDate, “there is no single historical feature, physical finding, laboratory test, or imaging study with sufficient specificity by itself to establish the diagnosis without the presence of additional abnormalities. Thus, the presence of a combination of features together with the exclusion of other diagnoses that may explain such symptoms or findings is necessary to arrive at an accurate diagnosis” .

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