How Medicare will cover your infusions is based on your diagnosis code. If your diagnosis code is listed here, you will be covered by Medicare Part B at 80% (after the yearly deductible). Your supplemental (Medigap) policy will then cover the remaining 20%.
If your diagnosis is not included on the PI diagnoses list, Ig replacement therapy will be covered under Medicare Part D. Click here to learn about Medicare Part D since coverage is different.
If you have a Medicare Advantage Plan and not the original Medicare with a Medigap plan, the Advantage Plan determines how claims are paid (Medicare B vs. D). Most patients on an Advantage Plan, even with a Medicare B qualifying diagnosis, end up owing high out-of-pocket costs.
Medicare plans vary from state to state and even in counties within a state. To help you select the appropriate plan, regardless of Part B or Part D, your State Health Insurance Assistance Program (SHIP) has trained counselors who can tell you the plans you are eligible for and help you find answers to your questions about coverage.
Please share the following information when you talk with the SHIP counselor or an insurance plan representative. This will help them accurately verify coverage or put you in touch with someone that can verify coverage.
- If your diagnosis is included in the PI diagnoses list, tell them your Ig therapy for primary immunodeficiency (PI) is a medical treatment covered under Medicare Part B. You should emphasize this since many of the counselors are used to dealing with Ig therapy covered under Part D for non-PI diagnoses.
- Regardless of your diagnosis, provide the billing code (J-code) for your product. (Your specialty pharmacy or immunologist’s billing office can provide this code.)
- Provide your PI diagnosis code. (If your diagnosis is PI, refer to the link in paragraph one above.) If your diagnosis is not included in the PI diagnosis list, consult your healthcare provider to receive the diagnosis code.
Additional Information for Individuals with a PI diagnosis covered by Medicare Part B:
- Click here if you receive IVIG for a PI diagnosis and want in-home infusions. This service is available by enrolling in the IVIG Demonstration Program. Although this is an extra step, there is no cost to participate in the program.
- Click here to view a video about Medicare coverage with a PI diagnosis