How Does Medicare Cover Gout?

If you have gout, you know that flare-ups are unexpected and extremely painful. The good news is that treatment is available manage the pain and even reduce the frequency of attacks and potential for complications.

If you have Medicare, here’s what you should know about how Medicare covers diagnosing and treating acute and chronic gout.

Medicare and Gout Diagnosis

Gout is a form of arthritis with unique, unsubtle symptoms, which means it’s generally easy for your doctor to diagnose without a lot of additional medical tests. In some cases, the symptoms may mimic a bacterial infection in the joint, requiring additional testing to confirm the presence of gout.

In addition, there are several tests and procedures your doctor may recommend to determine the level of uric acid and creatinine in your blood, and to check for the presence of urate crystals in asymptomatic joints.

These tests and procedures may include:

• Joint fluid aspiration to detect urate crystals.
• Bloodwork to rule out infections and check uric acid levels.
• Ultrasound to detect tophi if chronic tophaceous gout is suspected.
• CT scans to look for crystals in joints, although these are rarely ordered.

What Medicare Covers

Part B covers all medically necessary doctor visits and outpatient tests to diagnose gout. You pay 20% of the allowable charges after your Part B deductible is met. If you have enrolled in a Medigap plan, then that coverage will cover some or all of that 20% depending on which plan you enroll.

If you have a Medicare Advantage plan, your cost-sharing may be different. You may pay a flat copayment amount for doctor visits and outpatient tests, and you may or may not have a deductible. Check your plan’s Summary of Benefits for specifics on what you should expect to pay.

Medicare and Gout Treatment

Gout treatment has three objectives—to manage the pain and symptoms of an acute attack, to prevent or reduce the frequency of attacks, and to prevent complications from gout.

Most gout treatment is in the form of medications, which may include:

• Over-the-counter non-steroidal anti-inflammatory medications (NSAIDs) such as ibuprofen and naproxen to treat pain.
• Prescription pain medications such as Indocin or Celebrex.
• Colchicine, which can be used for both pain relief during an acute attack, and as a daily treatment to prevent future attacks.
• Corticosteroids to treat joint inflammation and pain. These can be taken as an oral medication in pill form or injected into the affected joints.
• Prescription medications such as Aloprim and Uloric that block the production of uric acid.
• Prescription drugs known as uricosurics (Probalan, Zurampic) that help your kidneys remove uric acid from the body.

During an acute attack, you may also wear a protective boot to take pressure off the affected joint to help relieve pain. Some people also use a cane to limit the pressure on painful joints when they walk.

What Medicare Covers

Original Medicare doesn’t generally cover any retail outpatient prescription drugs or over-the-counter medications you take at home, so most gout treatment isn’t covered under Part B. The only exception is steroid injections given in your doctor’s office. Part B pays 80% of allowable charges for a steroid injection.

However, if you have Part D coverage for your prescription drugs, then most, if not all, gout treatment prescriptions should be covered. Depending on the plan you choose, you may have a percentage-based cost-sharing structure or a flat copayment. Some plans have tiered cost-sharing structures, in which your out-of-pocket costs are lower for less expensive generic drugs and higher for specialty and brand-name medications.

Some Part D plans do help offset the cost of over-the-counter medications, but you should consult your specific plan for benefit details for over-the-counter drugs.

If your doctor prescribes a boot or other medical equipment, such as a cane, Part B may cover 80% of allowable charges. These devices are considered durable medical equipment, and if both your doctor and your equipment supplier participate with Medicare, you pay just 20% for medically necessary devices and equipment.

Other Medicare Coverage for Gout

Your doctor may suggest diet and lifestyle changes to help reduce your risk of complications from gout and prevent future attacks. This may include losing weight since overweight people produce more uric acid and their kidneys aren’t as effective at removing it.

If you are overweight with a BMI of 30 or more, Medicare covers weight loss counseling sessions by a qualified provider. You pay nothing for these sessions under Part B.

Certain medications, such as diuretics used to treat hypertension, may actually increase uric acid levels. If you are on multiple medications to treat different medical conditions, and you are enrolled in a Part D prescription drug plan, you may be eligible for medication therapy management services by a registered pharmacist.

During medication therapy management, your pharmacist will take an in-depth look at the medications you currently take and talk to you about how they are working, any side effects you’re experiencing, and how the medications together might actually worsen other conditions or cause additional side effects. He or she will also look for ways to help lower your medication costs.

After your consultation, the pharmacist works with your doctor to make sure the medications you take are actually improving your health. You’ll get a written report and an action plan to help you get the most benefit out of your prescription medications. You may be eligible for these services once a year at no cost to you. Check with your Part D plan for details, and if there are restrictions on the pharmacist you see for your medication therapy management services.

Danielle K Roberts and her team at Boomer Benefits assist Medicare beneficiaries with understanding their benefits and supplemental plan options. You can read more about them here.