Navigating the world of health insurance

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. 
  • Home IVIG becomes a permanent Medicare benefit in 2024
• Click here to view a video about Medicare coverage with a PI diagnosis

If you are commercially insured (not on a federally funded plan), contact the manufacturer of your Ig therapy product to enroll in their copay assistance program.

• Federally funded plans include but are not limited to Medicaid, Medicare (including Medicare Part D), Tricare, Medigap, VA, DoD, or other federal or state programs (including any medical or state prescription drug assistance programs).

There are also nonprofit organizations that might be able to provide copay/premium assistance to individuals diagnosed with PI. If assistance is currently not available, inquire about being added to the waitlist.

Accessia Health:  

• Website: Accessia Health Patient Programs
• Phone: 800-366-7741

The Assistance Fund (TAF):

• Website: TAF Primary Immunodeficiency Financial Assistance Program
• Phone: 855-256-4856

Patient Advocate Foundation (PAF): 

• Website: PAF Primary Immunodeficiency
• Phone: 866-512-3861

Financial hardship programs

• Ask your specialty pharmacy if they offer a financial hardship program where the amount you owe can be reduced or eliminated. Specialty pharmacies cannot offer this to you. You have to ask.
• Major medical centers (if you are getting your infusions done at a hospital or infusion suite) often offer programs where the amount you owe can be reduced or eliminated based on income. This information is often available on their website or by calling patient relations.

We also recommend signing up for PAN Foundation FundFinder. 

• Phone: 866-316-7263
• FundFinder is a free website that helps you track more than 200 patient assistance funds from nine charitable organizations. You can sign up for email and text alerts when a disease assistance fund you’re interested in opens at PAN or other organizations.