Is Clevatess covered by Medicare?

Is Clevatess covered by Medicare? Unfortunately, Medicare does not currently cover Clevatess (burosumab-twza), the FDA-approved treatment for X-linked hypophosphatemia (XLH) and tumor-induced osteomalacia (TIO).

Understanding Clevatess Coverage Limitations

Clevatess, manufactured by Ultragenyx Pharmaceutical, is a specialized biologic medication that requires significant financial investment. As a relatively new treatment approved in 2018, it hasn't been added to Medicare's standard formulary coverage list. This presents challenges for Medicare beneficiaries who need this essential therapy for rare bone disorders.

Alternative Coverage Options

Medicare Advantage Plans

Some Medicare Advantage plans may offer coverage for Clevatess, as these private plans can provide benefits beyond traditional Medicare. Coverage varies significantly between plans and regions, so reviewing your specific plan's formulary is crucial.

Medicare Part D

While traditional Medicare Part D typically doesn't cover Clevatess, some plans may offer limited coverage or prior authorization pathways. However, even with coverage, out-of-pocket costs can be substantial due to the medication's high price point.

Financial Assistance Programs

Manufacturer Support

Ultragenyx offers patient assistance programs that may help reduce costs for eligible patients, including those with Medicare coverage. These programs can provide significant savings for qualifying individuals.

State Medicaid Programs

Dual-eligible beneficiaries (those with both Medicare and Medicaid) may find coverage through their state's Medicaid program, which sometimes covers medications not included in Medicare formularies.

Planning for Treatment Costs

Given Clevatess's annual cost can exceed $300,000, exploring all available options is essential. Patients should work closely with their healthcare providers, insurance representatives, and pharmaceutical company patient advocates to identify potential coverage pathways.

Navigating Clevatess coverage requires careful planning and advocacy. Contact your Medicare plan directly and explore manufacturer assistance programs to determine your best options for accessing this important treatment.