Does Medicare Cover Stelara?

Hey there! If you're reading this, you're probably wondering whether Medicare will help cover the cost of Stelara. I get it navigating insurance coverage for medications can feel like trying to solve a puzzle with half the pieces missing. Let's chat about this together and break down exactly what you need to know.

Here's the straightforward answer: Yes, Medicare typically does cover Stelara, but it's not quite as simple as a yes or no question. The details really matter when it comes to your wallet. So if you're ready to dive a bit deeper and understand how this works, keep reading we're going to walk through everything step by step.

Understanding Stelara

Before we jump into the nitty-gritty of Medicare coverage, let's take a moment to understand what Stelara actually is. Think of it as your body's peacekeeper it helps calm down an overactive immune system that's causing trouble.

Stelara is primarily used to treat several autoimmune conditions that can really impact your quality of life. We're talking about:

• Psoriasis those stubborn, scaly patches that just won't quit
• Psoriatic arthritis when joint pain crashes the psoriasis party
• Crohn's disease inflammation in your digestive tract that makes everything uncomfortable
• Ulcerative colitis similar to Crohn's but affects your colon and rectum

Now, here's the interesting part about how you actually get Stelara. It comes in two forms:

• A subcutaneous injection that you can give yourself at home
• An intravenous (IV) infusion that's administered at a healthcare facility

The way you receive it actually plays a pretty big role in how Medicare covers it which brings us to our next topic.

Medicare Coverage Basics

Let's talk about the big changes that happened in 2023, because they really shifted how things work for people taking Stelara. This is where things get a bit tricky, so stay with me here.

Previously, if you were getting Stelara through an IV infusion at a doctor's office or clinic, Medicare Part B would typically cover it. That made sense you're getting medical care in a clinical setting. But here's the twist: Medicare changed its policies in 2023, and now self-administered drugs (like the at-home injections you give yourself) are no longer covered under Part B.

So what does that mean for you?

If you're giving yourself Stelara injections at home, Medicare Part B won't cover it anymore. That responsibility has shifted to Medicare Part D, which is your prescription drug coverage. However, if you're still receiving Stelara through IV infusions at a medical facility, Part B coverage may still apply.

This change didn't happen out of nowhere according to a report from the U.S. Department of Health and Human Services, between 2016 and 2023, Medicare spent almost ten times more on Stelara, jumping from $300 million to a whopping $3 billion. That's a pretty significant increase that definitely caught people's attention!

How Medicare Part D Works

Now that we know Stelara falls under Part D for most people, let's break down what that actually means for your coverage. Think of Part D like a menu at your favorite restaurant not all plans are created equal, and what's included can vary quite a bit.

Here's the thing about prescription drug plans they're not one-size-fits-all. Each plan has its own formulary (that's just a fancy word for their list of covered medications), and they organize these medications into different tiers. Stelara might be placed in a higher-cost tier, which means you'll pay more out of pocket.

Some plans might:

• Put Stelara in a premium tier with higher copays
• Not cover certain biosimilar versions
• Require prior authorization before approving coverage

This is why it's so important to actually check your specific plan details. What works for your neighbor might not work for you, and that's perfectly normal.

Let's talk numbers for a moment, because I know that's what really matters to most people. Here's what you might expect:

Expense Type	What to Expect
Monthly Premium	Varies by plan (~$36.78 average in 2025)
Deductible	Up to $590/year (maximum allowed)
Coinsurance/Copay	Typically 25% until reaching catastrophic coverage
Catastrophic Coverage	Kicks in after $2,000 out-of-pocket costs

These numbers might seem overwhelming, but here's a pro tip that could save you some serious money: use the Medicare Plan Finder tool to see exactly what your current plan covers and whether there might be better options available.

Finding Ways to Save

I know what you're probably thinking these costs can add up quickly, especially if you're on a fixed income. The good news? There are several strategies that can help lighten the financial load.

First up, let's talk about the Extra Help program. This is a lifeline for many people, and it's designed to help those with limited income and resources. If you qualify, this program can significantly reduce or even eliminate your premiums, deductibles, and copays for prescription medications like Stelara.

You might be wondering, "How do I know if I qualify?" The best approach is to check directly with Medicare they can guide you through the application process and help you understand what benefits you might be eligible for.

But that's not the only option. Have you considered talking to your doctor about biosimilar options? These are medications that are similar to the original brand-name drug but often come at a lower cost. They go through rigorous testing to ensure they're just as effective and safe.

And here's something that really warms my heart the pharmaceutical companies themselves often have assistance programs. For Stelara specifically, there's J&J's withMe patient support program that offers various forms of assistance to eligible patients.

Don't forget to check if your state offers any pharmaceutical assistance programs either. These can vary widely from state to state, but they're definitely worth exploring.

Medicare Advantage Options

If you're enrolled in a Medicare Advantage plan (sometimes called Medicare Part C), you have another layer to consider. Many of these plans include prescription drug coverage as part of their package, which can be really convenient.

The catch? Just like with standalone Part D plans, not all Medicare Advantage plans are the same. Your copays, coinsurance, and deductibles can vary significantly from one plan to another. This is why it's so important to review your options annually during open enrollment.

What I love about Medicare Advantage plans is that they often bundle everything together medical coverage, prescription drugs, and sometimes even additional benefits like dental or vision. It can make managing your healthcare a bit simpler.

If you're thinking about switching plans, you absolutely can do that. Whether you want to move from Original Medicare to a Medicare Advantage plan, or vice versa, there are specific enrollment periods that allow you to make these changes. Just make sure you understand the timing so you don't end up with a gap in coverage.

Making Informed Decisions

As we wrap up this conversation, let's take a step back and look at the bigger picture. When it comes to Medicare coverage for Stelara, there are definitely pros and cons to weigh.

On the positive side:

• Medicare does help cover this expensive medication
• Financial assistance programs are available for those who qualify
• You have options through both Part D and Medicare Advantage plans

On the flip side:

• You might still face significant out-of-pocket costs
• Plan differences mean coverage isn't always consistent
• Navigating all the options can feel overwhelming

Remember, you're not alone in this. So many people are navigating the same challenges, and there are resources and support systems available to help you through it.

Here's what I want you to take away from all of this: Knowledge is power. The more you understand about your coverage options, the better equipped you'll be to make decisions that work for your unique situation and budget.

Final Thoughts

So does Medicare cover Stelara? For most people, the answer is yes but under Part D or through a Medicare Advantage plan that includes prescription drug coverage. The key is understanding exactly how and where it's covered, because those details can make a huge difference in what you actually pay out of pocket.

I know this can feel like a lot to process, especially when you're already dealing with the challenges of managing an autoimmune condition. But please don't let that discourage you from exploring your options and finding the best path forward.

The reality is that even with Medicare coverage, you might still be responsible for hundreds or even thousands of dollars unless you take proactive steps to reduce your expenses. That's why it's so important to look into programs like Extra Help, manufacturer assistance programs, and potentially switching to a more cost-effective plan.

If you're feeling a bit overwhelmed right now, that's completely normal and understandable. This is complicated stuff, and it's okay to take your time working through it. Consider sitting down with a family member or friend to help you navigate the options, or reach out to a Medicare counselor who can provide personalized guidance.

What matters most is that you don't give up. There are resources available, and there are people ready to help you find the best solution for your situation. Stay informed, ask questions, and remember that you have more options than you might realize.

Your health and wellbeing are worth the effort it takes to figure this out. Take it one step at a time, and you'll get there.

Disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult with a healthcare professional before starting any new treatment regimen.