Medicare Coverage for MS Infusion Treatments: Ocrevus, Tysabri, and More

If you receive MS infusion treatments like Ocrevus, Tysabri, or Lemtrada, Medicare Part B will cover these medications when they're given in a doctor's office or infusion center. But here's what many patients don't realize: that 20% coinsurance you're responsible for can mean paying $1,000 or more per infusion—potentially $13,000 annually for a drug like Ocrevus.

The most common MS infusions—Ocrevus (twice yearly), Tysabri (monthly), Lemtrada (annual courses), and the newer Briumvi—all fall under Medicare Part B because they must be administered by healthcare professionals. This means different rules, costs, and authorization requirements than the self-administered medications covered by Part D.

Understanding these coverage rules, navigating the prior authorization process, and finding financial assistance can mean the difference between getting the treatment you need and facing impossible costs. Let's break down exactly how Medicare covers these vital treatments and how to maximize your benefits.

Medicare Parts and MS Medication Coverage

Medicare divides medication coverage into distinct parts, and knowing which part covers your MS treatment directly impacts what you'll pay and how to get approval.

Part B Coverage handles infusions given in your doctor's office or infusion center. After you meet your $257 annual deductible, you pay 20% of the Medicare-approved amount with no yearly maximum. This covers the drug itself, the equipment needed to infuse it, and the healthcare professional administering it. Part B covers drugs that can't be self-administered and require medical supervision, which includes all MS infusion therapies.

Part D Coverage is for medications you can give yourself at home, including injectable MS drugs like Copaxone or Gilenya pills. Starting in 2025, Part D has a $2,000 yearly cap on what you pay out-of-pocket, but this doesn't help with Part B infusions. The coverage gap or "donut hole" that used to leave patients paying more mid-year has been eliminated under recent Medicare changes.

Part A Coverage only applies when you're formally admitted to the hospital as an inpatient. If you're just under observation status—even if you stay overnight—you're still considered an outpatient under Part B, which can mean multiple separate copayments. This technicality can cost thousands more than expected.

Understanding coverage gaps is crucial. Original Medicare has no out-of-pocket maximum for Part B services, meaning your 20% coinsurance for expensive infusions continues all year without limit. Medicare Advantage plans cap your yearly costs at $9,350 for in-network services in 2025, but they require prior authorization and limit which providers you can see.

Common MS Infusions and Coverage

Each MS infusion therapy has unique administration schedules and monitoring requirements that affect your Medicare coverage and costs.

Ocrevus (ocrelizumab) requires infusions just twice yearly, making it convenient for many patients. It's the only infusion approved for primary progressive MS and costs about $65,000 annually, though actual Medicare payments average $104,853 due to facility markups. Medicare Part B covers it when given in approved settings, but your 20% share means roughly $13,000 yearly out-of-pocket.

Tysabri (natalizumab) demands monthly infusions, creating more frequent copayments. It generates about 7.8 Medicare claims annually compared to Ocrevus's 1.8 claims, substantially increasing total costs. The drug requires enrollment in the TOUCH Prescribing Program due to PML (brain infection) risk, with mandatory JC virus testing that Medicare also covers under Part B.

Lemtrada (alemtuzumab) works differently with five consecutive infusion days in year one, three days in year two, then potentially no more treatment. As a second-line therapy, Medicare requires proof you've tried at least two other MS medications first. The intensive monitoring for thyroid problems and other side effects means additional covered services and copayments.

Briumvi (ublituximab), approved in late 2022, offers the shortest infusion time at just one hour for maintenance doses. At $59,000 annually, it costs slightly less than competitors and works similarly to Ocrevus by targeting B cells. Coverage is still stabilizing as insurance companies develop their policies for this newer option.

Kesimpta (ofatumumab) differs because patients self-inject it monthly at home, placing it under Part D rather than Part B. This means the new $2,000 yearly cap applies, potentially making it more affordable than infusions despite similar effectiveness.

Prior Authorization and Documentation

Getting Medicare to approve your MS infusion often requires jumping through hoops, but understanding the process helps you prepare for success.

About 50% of MS medication prior authorizations are initially denied, making proper documentation critical from the start. Your neurologist must provide confirmed MS diagnosis using McDonald Criteria, MRI results showing active disease, documented relapses or disability progression, and explanation of why this specific medication is appropriate for you.

Step therapy requirements force many patients to "fail" cheaper drugs first. For Lemtrada, Medicare requires at least six months trying two other disease-modifying therapies, with specific documentation of why they didn't work—new relapses, MRI activity, or intolerable side effects. This can delay access to preferred treatments by months or years.

Medical necessity documentation goes beyond just stating you have MS. Insurance companies want objective evidence: recent MRI reports showing new or enlarging lesions, relapse documentation with dates and symptoms, EDSS scores showing disability progression, and your neurologist's detailed explanation of why alternative treatments won't work for your specific situation.

Medicare Advantage plans must make prior authorization decisions within 7 days for standard requests or 24 hours for urgent cases. But initial denials aren't the end—82% of Medicare Advantage appeals succeed when pursued through higher levels, though only 11% of patients actually appeal. Don't accept "no" as the final answer.

Managing Infusion Costs

The financial burden of MS infusions can feel overwhelming, but several strategies can significantly reduce your costs.

Your location choice dramatically affects costs. According to the Infusion Providers Alliance, independent infusion centers can save patients up to 50% compared to hospital outpatient departments for the same services. Hospitals add facility fees and higher overhead costs that Medicare passes on to you through your 20% coinsurance. Since you pay a percentage of whatever Medicare is charged, getting your infusion at a lower-cost facility directly reduces your out-of-pocket expenses. Over a year of monthly infusions, choosing the right location can save thousands.

Financial assistance programs offer crucial support, but Medicare patients can't use manufacturer copay cards—that's illegal under federal anti-kickback laws. Instead, you can access independent foundations:

• HealthWell Foundation: Provides average grants of $3,000 for MS patients with Medicare, requiring income up to 300-500% of Federal Poverty Level
• Patient Access Network (PAN) Foundation: Offers up to $8,000 annually with instant online approval when funds are available
• Patient Advocate Foundation Co-Pay Relief: Provides immediate pharmacy cards for eligible patients

These foundations operate first-come, first-served with limited funding that opens and closes throughout the year. Sign up for notifications and apply immediately when funds become available. The difference between getting assistance and missing out often comes down to acting within hours of funds opening.

Medigap supplemental insurance offers the most comprehensive cost protection. Plan G covers your entire 20% Part B coinsurance after you meet the $257 deductible, reducing annual costs from potentially $15,000+ to just the deductible plus monthly premiums averaging $217.

How a Solace Advocate Maximizes Your MS Coverage

When you're dealing with a chronic condition like MS, the last thing you need is to spend hours fighting insurance companies. That's where a Solace MS advocate makes all the difference.

Prior Authorization Management becomes manageable with expert help. Your advocate knows exactly what documentation insurance companies need to see. They work with your neurologist to compile compelling medical evidence, submit comprehensive prior authorization requests that address common denial reasons upfront, and track submission deadlines so nothing falls through the cracks. When plans require step therapy documentation, advocates ensure every failed medication is properly documented with specific dates, doses, and outcomes.

Insurance Appeals are where advocates truly shine. With a 54% success rate overturning denials, Solace advocates understand the five-level Medicare appeals process and which arguments work at each stage. They prepare physician letters explaining medical necessity, gather supporting medical literature and clinical guidelines, meet tight appeal deadlines (you only have 60-120 days), and persist through multiple levels when needed.

Financial Assistance requires constant vigilance since foundation funds open and close unpredictably. Advocates monitor multiple foundations simultaneously, submit applications within hours of funds opening, maintain your eligibility documentation across multiple programs, and find alternative resources when primary foundations are closed.

Treatment Coordination ensures nothing disrupts your care. Advocates verify your infusion center stays in-network, coordinate required monitoring like JC virus testing for Tysabri, manage documentation for restricted programs like TOUCH, and ensure prior authorizations get renewed before expiring. They also help select facilities that minimize your costs while maintaining quality care, potentially saving thousands annually just through strategic site selection.

Frequently Asked Questions About Medicare Coverage of MS Infusion Treatments

Q: Why does Medicare Part B cover infusions but not self-injected medications?

A: Medicare Part B covers drugs that require professional administration and can't be self-administered safely at home. Infusions need IV access, monitoring during administration, and immediate access to emergency care if reactions occur. Self-injected drugs like Kesimpta fall under Part D because patients can safely administer them at home.

Q: Can I use the drug manufacturer's copay assistance program with Medicare?

A: No, federal Anti-Kickback Statute prohibits pharmaceutical manufacturers from offering copay assistance to Medicare beneficiaries. This is actually a felony that could result in fines and imprisonment. Instead, Medicare patients must use independent charitable foundations like HealthWell or PAN that operate separately from drug companies.

Q: Will Medicare Advantage cover my MS infusions differently than Original Medicare?

A: Medicare Advantage must cover everything Original Medicare does, but with key differences. MA plans require prior authorization for most infusions and limit you to in-network providers, but cap your annual out-of-pocket costs at $9,350. Original Medicare lets you see any provider who accepts Medicare but has no out-of-pocket maximum unless you have Medigap.

Q: What happens if my prior authorization is denied?

A: Don't give up! File an appeal immediately—you usually have 60-120 days. The five-level appeals process starts with redetermination, and 82% of Medicare Advantage appeals that go through multiple levels eventually succeed. Get your neurologist to write a detailed letter explaining medical necessity, and consider getting help from a Solace advocate or free SHIP counselor.

Q: How much will my MS infusions cost me each year?

A: With Original Medicare alone, you'll pay 20% of the Medicare-approved amount after your $257 deductible. For Ocrevus at $65,000 yearly, that's about $13,000 out-of-pocket just for the drug. Add administration fees, facility charges, and other medical costs, and many patients face $15,000-20,000 annually. Medigap Plan G reduces this to just the $257 deductible plus premiums, while Medicare Advantage caps total costs at $9,350 but requires using network providers.

This article is for informational purposes only and should not be substituted for professional advice. Information is subject to change. Consult your healthcare provider or a qualified professional for guidance on medical issues, financial concerns, or healthcare benefits.

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