Does Medicare Cover Otezla? 

Psoriasis is a common and uncomfortable skin condition that typically develops as a rash. People who experience psoriasis will usually have itchy skin along with redness, inflammation and shedding. In most cases, psoriasis on its own isn’t life-threatening, and while treatments exist to reduce symptoms during flare-ups, there is no cure for psoriasis. 

Plaque psoriasis is the most common form of the condition. It can cause rashes to develop along the hairline, where skin makes contact with other parts of the body and along joints like elbows and knees. Despite the relatively mild danger that psoriasis presents to health, some people develop a more complex condition known as psoriatic arthritis. Like rheumatoid arthritis, psoriatic arthritis is a disease directly affected by the immune system. However, unlike rheumatoid arthritis, psoriatic arthritis attacks the skin surrounding arthritic joints. This adds to redness in the affected area and leads to skin shedding.

If you have Medicare and have been diagnosed with psoriatic arthritis, you may be wondering how Medicare will help cover the cost of treatment. 

How is psoriatic arthritis diagnosed?

In order to treat psoriatic arthritis, you’ll need to work with your doctors to obtain an official diagnosis. This is usually done by checking levels of C-reactive proteins and the rate of erythrocyte sedimentation. Additionally, diagnostic tests using magnetic resonance imaging (MRI) and traditional x-rays may be needed to locate and isolate joints affected by arthritis that leads to psoriasis. Your Medicare Part B benefits can help cover the costs of medically necessary screenings and doctor visits. 

How is psoriatic arthritis treated?

Treatment options for psoriatic arthritis are generally limited to the severity of the condition. For some seniors, oral steroids, combined with over-the-counter anti-inflammatory medications, may be enough to keep symptoms under control. However, steroid injections may be needed in moderate cases of psoriatic arthritis. Additionally, prescription medications like Otezla (apremilast) may be ordered by your doctor to treat the symptoms of plaque psoriasis and psoriatic arthritis.

Does Medicare cover Otezla?

Original Medicare insurance helps to cover the cost of prescription drugs through Medicare Part D. Although this part of Medicare coverage only became available in 2006, tens of millions of seniors, and some people under the age of 65 who qualify for Medicare due to disability, have been able to use these benefits to pay for the cost of medications purchased from retail pharmacies. 

Medicare coverage for Otezla requires that the drug be found in your plan’s formulary, a list of covered prescriptions. If your Medicare insurance plan covers Otezla, you may face a copay when picking up your prescription. Medicare Part D plans also require a monthly premium and a deductible. Your premium is set by your plan provider. Although deductibles can vary, no Part D deductible can be higher than $505 for 2023.

Income-related monthly adjustment amount

It’s important to note that the Centers for Medicare & Medicaid Services (CMS) may impose an additional Part D premium. This is what’s known as an income-related monthly adjustment amount (IRMAA), and it is based on your income as reported by the Social Security Administration (SSA).

Medicare recipients with a higher income will face a higher additional monthly premium cost. For 2023, the highest earners, meaning those with an annual income of $500,000 or greater, can expect to pay an additional $76.40 per month in addition to their Medicare coverage premiums for Part D benefits.

Medicare Advantage and Otezla coverage

If you opt for a Medicare Advantage plan instead of Original Medicare coverage, your plan may include Part D coverage. Otezla coverage is still determined by your plan’s formulary. To learn more, you are encouraged to speak with your Medicare Advantage plan provider.