The Essential Guide to Medicare IVIG Coverage

Medicare provides coverage for IVIG and SCIG therapies in many instances, but navigating the details can sometimes be difficult. This guide will provide an overview of how IG therapies are covered under Medicare.

Medicare will provide coverage for IVIG based on:

• The diagnosis
• The location of therapy
• The route of administration 

Diagnosis codes and other criteria are used to determine whether IVIG is covered by Medicare Part B. If you have a condition that is not covered by Part B, you may still be covered by Medicare Part D if your condition is listed as an FDA-approved IVIG indication.

Medicare IVIG Coverage Under Part B

IVIG is covered under Medicare Part B if the following criteria are met:

1. IVIG is administered at home.
2. IVIG is administered through an infusion pump.
3. The treating physician has determined that the administration of IVIG at home is medically appropriate.
4. The patient is diagnosed with primary immunodeficiency disease with one of the diagnosis codes listed below.

Medicare-covered Diagnosis Codes for Part B:

Medicare will pay 80% of the drug cost. The other 20% must be covered by a supplemental plan or by the patient. Under Part B, only the drug cost is covered. Supplies and infusion pumps are not covered unless they are for CIDP.

For CIDP, Medicare will also pay for 80% of the cost of supplies and infusion pumps. As of July 2021, only subcutaneous IG therapy (such as Hizentra and Hyqvia) for CIDP is covered under Part B.

Medicare IVIG Coverage Under Part D

For diagnoses that are not covered under Part B, Part D coverage may apply if the condition is an FDA-approved IVIG indication (see below).

Medicare-Covered FDA-approved Indications for IVIG

• Primary immunodeficiency
• Myasthenia gravis
• Chronic inflammatory demyelinating polyneuropathy (CIDP)
• Immune thrombocytopenic purpura (ITP)
• B-cell chronic lymphocytic leukemia (CLL)
• Stiff-person syndrome
• Bone marrow transplant/hematopoietic stem cell transplant
• Dermatomyositis
• Polymyositis
• Multifocal motor neuropathy
• HIV infection
• Guillain-Barre syndrome
• Lambert-Eaton myasthenic syndrome
• Parvovirus B19-induced pure red cell aplasia
• Kawasaki syndrome (pediatric)
• Fetal/neonatal alloimmune thrombocytopenia
• Isoimmune hemolytic disease of newborn
• Neonatal hemochromatosis
• Immune checkpoint inhibitor-related toxicity
• CAR-T therapy-related hypogammaglobulinemia
• Acquire red cell aplasia
• Acute disseminated encephalomyelitis
• Rasmussen encephalitis
• Enteroviral meningoencephalitis
• Autoimmune mucocutaneous blistering disease
• Autoimmune hemolytic anemia
• Autoimmune neutropenia
• Systemic lupus erythematosus
• Birdshot retinochoroidopathy
• BK virus-associated nephropathy
• Churg-Strauss syndrome
• Hematophagocytic lymphohistiocytosis (HLH)
• Macrophage Activation Syndrome (MAS)
• Hyperimmunoglobulinemia E syndrome
• Multiple myeloma
• Opsoclonus-myoclonus
• Post-transfusion purpura
• Solid organ transplantation
• Major surgery associated secondary immunosuppression
• Hematologic malignancy-associated secondary immunosuppression
• Major burns associated secondary immunosuppression
• Collagen-vascular disease-associated secondary immunosuppression
• Toxic epidermal necrolysis
• Stevens-Johnson syndrome
• Toxic shock syndrome
• Toxic necrotizing fasciitis

Standard Part D benefit and copay structures apply. 

For more information on out-of-pocket expenses for Part D, visit the Q1Medicare site.

Nursing Costs for IVIG

Nursing costs for IVIG are covered under the Original Medicare or Medicare Advantage plan. For Original Medicare, 80% of the costs will be covered by the plan, and either a supplemental plan or the patient will be responsible for the remaining 20%. 

Costs will vary under Medicare Advantage. A full benefits investigation is necessary to determine the exact cost. Speak to an AmeriPharma™ billing specialist for more information.

Copay Assistance

AmeriPharma™ offers assistance to help with any remaining copay you may have on IVIG after using Medicare. Using advanced software, AmeriPharma™ will review all available funding sources and match you with a program that fits your needs. A copay specialist will help you with the application process.

For more information, speak to one of our specialists about how AmeriPharma™ can help.

How to Enroll in Medicare

You may sign up for Medicare online, by phone, or in person at your local Social Security office.

Medicare enrollment is available during a 7-month enrollment period that starts 3 months before you turn 65. You must enroll in Medicare prior to turning 65 if you want your coverage to start on the month you turn 65. You may also enroll in Medicare up to 3 months after the month you turn 65, as outlined on the Medicare website. 

Individuals with specific disabilities may qualify for Medicare before they turn 65 years old.

The 2024 Medicare Open Enrollment period will take place from October 15 to December 7, 2024. Changes made during this time will go into effect on January 1, 2025. 

During this time, Medicare enrollees can review and make changes to their current coverage, including cost, coverage, and provider and pharmacy networks. 

Medicare’s Open Enrollment period is also known as the “annual enrollment period” or “AEP”. There may also be other times during the year when people can enroll in a plan, which are called “open enrollment” or “special enrollment” periods. 

For more information, visit medicare.gov.

The Inflation Reduction Act

Thanks to the Biden-Harris Administration’s Inflation Reduction Act (IRA), also known as the prescription drug law, people with Medicare prescription drug coverage (Part D) in 2025 will have the most comprehensive benefits since the program was launched in 2006. In 2025, all people enrolled in Part D will have their annual out-of-pocket prescription drug costs capped at $2,000 per year. Additionally, the Medicare Prescription Payment Plan, which will be offered by all Part D plans starting next year, will allow people with Medicare Part D coverage the option to spread the costs of their prescription drugs over the calendar year.

FAQs

Does Medicare cover IVIG for CIDP?

Yes. For CIDP, Medicare will pay for 80% of the cost of the drug and supplies. The other 20% must be covered by a supplemental plan or by the patient. As of July 2021, only subcutaneous IG therapy (such as Hizentra and Hyqvia) for CIDP is covered under Part B. 

Does Medicare cover IVIG for Guillain-Barre syndrome?

Yes. Medicare provides coverage for Guillain-Barre syndrome under Part D.

Does Medicare cover IVIG for Myasthenia Gravis?

Yes. Medicare provides coverage for Myasthenia gravis under Part D.

Is Privigen covered by Medicare?

Yes, Privigen (J1459) is covered under Medicare Part B. 

Is Gamunex covered by Medicare?

Yes, Gamunex (J1561) is covered under Medicare Part B.