Does Medicare Part B Still Cover Stelara?

Hey there! I know how overwhelming it can feel when you're trying to figure out Medicare coverage for your medications especially something like Stelara that's so important for managing chronic conditions. If you're reading this, you're probably wondering: does Medicare Part B cover Stelara? Let me walk you through what's really happening with this medication and your Medicare coverage.

I've been researching Medicare policies for years, and I remember when this change happened it definitely caught a lot of people off guard. The short answer is no, Medicare Part B doesn't cover Stelara anymore. But here's where things get interesting: Medicare Part D often does! And that's actually good news, even though it might not feel that way right now.

Understanding Stelara

Before we dive into the coverage details, let's make sure we're all on the same page about what Stelara actually is. Think of it as your body's personal mediator it helps calm down an overactive immune system that's causing problems.

Stelara works by targeting specific proteins in your immune system that trigger inflammation. For people dealing with conditions like psoriasis, psoriatic arthritis, Crohn's disease, or ulcerative colitis, this medication can be life-changing. I've heard from so many patients who say it's given them their life back allowing them to work, spend time with family, and enjoy activities they hadn't been able to in years.

Here's the thing though: Stelara isn't cheap. We're talking about several thousand dollars per injection, and most people need it regularly to keep their symptoms under control. That's why figuring out insurance coverage isn't just about convenience it's literally about being able to afford your treatment.

Medicare Coverage Basics

Let's break down the Medicare parts so we're all speaking the same language. Picture Medicare like a two-part system:

Medicare Part B is like your medical insurance it covers doctor visits, tests, and medical equipment. For a while, it also covered self-administered drugs like Stelara injections that you give yourself at home.

Medicare Part D is your prescription drug coverage it's specifically designed for medications, whether you pick them up at a pharmacy or inject them yourself.

Here's where it gets tricky: as of January 1, 2023, Medicare made a significant change. They moved most self-administered injectable medications including Stelara from Part B coverage to Part D coverage. It was part of broader efforts to reduce drug costs and streamline coverage, but let's be honest any big change can feel confusing when you're already managing a chronic condition.

Current Coverage Reality

So what does this mean for you right now? Well, if you're looking for the simplest answer: Medicare Part B no longer covers Stelara injections that you give yourself at home. Period. That part is pretty straightforward, even if it's not what we might have hoped for.

The silver lining? Many Medicare Part D plans do cover Stelara. The catch and there's always a catch, isn't there? is that coverage can vary from plan to plan. Some plans cover it with lower copays, others might require prior authorization or have it on a higher tier that means you pay more out of pocket.

I always tell people: don't panic if you don't see Stelara listed in your plan's formulary right away. Plans update their formularies regularly, and there are usually ways to get coverage if your doctor documents that it's medically necessary.

Checking Your Coverage

Here's something I wish I'd known when I first started helping people navigate this process: checking your coverage doesn't have to be rocket science. You can actually do it yourself, and it only takes a few minutes.

Head over to Medicare.gov and use their formulary search tool it's incredibly user-friendly. Just type in "Stelara" and your zip code, and it'll show you which plans in your area cover it. You'll be able to see if it's on formulary (covered), what tier it's on (which affects your cost), and whether there are any restrictions.

The formulary is basically like a menu of covered drugs. Think of it as your grocery list for medications if it's on there, you're good to go. If it's not, or if it's listed with restrictions, that's when you might need to do a little more work with your doctor's office.

Understanding Stelara Costs

Let's talk numbers, because I know that's probably on your mind. Without insurance, Stelara can cost anywhere from $6,000 to $7,000 per injection. Yes, you read that right thousands of dollars. For most people, that's simply not feasible to pay out of pocket.

But here's the good news: with Medicare Part D coverage, you're typically only looking at a fraction of that cost. Depending on your plan and where Stelara falls on their formulary, you might pay anywhere from $200 to $1,000+ out of pocket. That's still a significant amount, but it's worlds different from paying the full price.

The exact amount you'll pay depends on a few factors: what tier your plan puts Stelara on, whether you've met your deductible yet, and whether you're in the coverage gap (sometimes called the "donut hole"). It sounds complicated, but it really comes down to this: the better your plan covers Stelara, the less you pay.

Ways to Reduce Costs

Now, I'm going to share something that might change your whole perspective on this situation. Have you ever heard of patient assistance programs? If not, get ready to have your mind blown these programs can be absolute game-changers.

Janssen, the company that makes Stelara, offers several programs that can dramatically reduce your out-of-pocket costs. Some people I've worked with have gone from paying hundreds of dollars to paying nothing at all. The catch? You have to apply, and you have to meet certain income requirements.

Even if you don't qualify for completely free medication, you might be eligible for programs that cap your monthly payments at $25 or $50. Think about that instead of potentially hundreds of dollars, you're looking at the cost of a nice dinner out.

Another thing to explore is Medicare's Extra Help program. If your income and resources fall below certain limits, you might qualify for additional assistance with your prescription drug costs. It's worth checking into, even if you're not sure you'll qualify the application process is straightforward, and the potential savings are substantial.

Getting Your Coverage Approved

Let's say you've found a Part D plan that covers Stelara, but there are restrictions. Maybe your plan requires prior authorization, or step therapy (trying other medications first), or both. This is where having a good relationship with your doctor's office becomes invaluable.

Prior authorization isn't about whether your doctor thinks you need the medication it's about whether your insurance company agrees. Your doctor's office will need to submit documentation showing why Stelara is medically necessary for you specifically. This might include details about other treatments you've tried, your medical history, and why those other options haven't worked.

From my experience, the key to getting prior authorization approved is thorough documentation from your doctor. The more specific they can be about why Stelara is the right choice for you, the better your chances of approval. If your initial request is denied and it happens more often than you might think don't give up. You can appeal the decision, and many appeals are successful.

Clarifying Common Confusion

I want to address a few things that seem to confuse people constantly, because misinformation can really complicate an already stressful situation.

First, if you have a doctor or nurse give you the injection in their office, Medicare Part B might cover the administration of the drug, but they still won't cover the cost of the Stelara itself. You'd need Part D coverage for that. This is one of those situations where you're dealing with two different parts of Medicare for one treatment.

Second, don't assume that just because one Part D plan covers Stelara, all of them do. Coverage can vary significantly between plans, even within the same insurance company. That's why checking your specific plan's formulary is so important.

Scenario	Medicare Part B	Medicare Part D
Self-administered Stelara	No coverage (2023+)	Often covered
Doctor-administered Stelara	Covers administration	Covers medication cost

Making Smart Medicare Choices

Here's something I've learned from working with people on Medicare for years: don't be afraid to ask for help. Medicare counselors, pharmacists, and even your insurance company's customer service representatives can provide valuable insights. These folks deal with these questions daily, and they can often explain complex situations in ways that actually make sense.

Your State Health Insurance Assistance Program (SHIP) is another incredible resource that's often overlooked. These programs provide free, unbiased counseling to Medicare beneficiaries. They can help you understand your coverage options, navigate prior authorizations, and even assist with appeals if your coverage is denied.

Don't wait until you're in crisis mode to reach out for help. The earlier you start exploring your options and asking questions, the better prepared you'll be when it's time to actually use your coverage.

Annual Planning and Review

One thing about Medicare Part D that catches people off guard is that plans can change from year to year. Just because your plan covers Stelara one year doesn't mean it will the next. That's why the Annual Enrollment Period (October 15 to December 7) is so important.

Every year during this period, take some time to review your plan's formulary. Check if Stelara is still covered, if the tier has changed, and if your out-of-pocket costs are different. You might find that switching to a different plan could save you hundreds or even thousands of dollars annually.

I know it sounds like a lot of work, especially when you're already managing a chronic condition. But think of it as an investment in your health and financial well-being. A few hours of research now could save you significant money throughout the year.

Moving Forward with Confidence

Let's circle back to where we started: does Medicare Part B cover Stelara? No, not anymore. But the story doesn't end there, and that's what I want you to remember. While Medicare Part B coverage has ended, Medicare Part D coverage is available and accessible for most people who need it.

The key is being proactive rather than reactive. Check your plan's formulary, explore patient assistance programs, maintain good communication with your doctor's office, and don't hesitate to ask questions or appeal decisions when necessary.

I've seen too many people struggle unnecessarily because they assumed there was nothing they could do about high medication costs. The truth is, there's almost always something you can do whether it's switching plans, applying for assistance programs, or working with your doctor to navigate insurance requirements.

You've already taken the most important step by seeking information and trying to understand your options. That shows you're taking control of your healthcare, and that's something to be proud of. Managing a chronic condition is challenging enough without adding the stress of figuring out insurance coverage, but remember you don't have to do it alone.

Keep asking questions, keep advocating for yourself, and remember that better days are ahead. With the right coverage in place, Stelara can help you live the life you deserve and that makes all the difference in the world.

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.