On December 22, 2004, the Centers for Disease Control and Prevention (CDC) expanded the group of individuals eligible to receive the flu shot so that most people over 50 and those in contact with people at high risk can obtain the vaccine. See http://www.cdc.gov/flu/ for updated information. In some states, including Connecticut, all restrictions on the vaccines have been lifted. Nonetheless, many people will still get the flu; for those who do, Medicare coverage may be available for medications that help relieve symptoms.

The Centers for Medicare & Medicaid Services (CMS) recently unveiled a Demonstration Project to pay for prescription medications that have been proven to combat the symptoms of the flu. In its press release about the new coverage CMS states that, “the project is designed to help determine if coverage for these medications can significantly reduce the impact of flu on Medicare beneficiaries, especially those currently without drug coverage”.  (http://www.cms.gov/media/press/release.asp?Counter=1309) CMS recognizes that the vaccine is still the best protection against the flu, but the antiviral drugs included in the demonstration project can help if the flu has been contracted.

The Demonstration Project began on December 31, 2004 and will end on May 31, 2005.  Pharmacies will have until December 31, 2005 to submit claims. The Project is designed for beneficiaries with Medicare Part B who do not have drug coverage. Beneficiaries can take their prescriptions to any Medicare-certified pharmacy to be filled.  If the Part B deductible has been met ($110 in 2005), Medicare will pay 80% of the cost of the drug, up to the Medicare allowed payment.  Medicare pays 96% of the average wholesale price for brand name drugs and 90% of the average wholesale price for generic drugs. Beneficiaries can get up to a total of two prescriptions filled during the Demonstration period.

Beneficiaries in Medicare’s Drug Discount Card program will pay 20% of their card sponsor’s negotiated price for the drug, or 20% of the Medicare allowed payment, whichever is less.  Individuals who qualify for drug card program’s low-income “Transitional Assistance” can use their $600 credit to pay for these medications. Beneficiaries who have a Medicare-covered hospital stay will have the antiviral medications covered as part of the hospital stay.

The antiviral medications can be taken after the flu symptoms occur.  The medications can be used in cases of outbreaks in communities, for residents of institutions such as skilled nursing facilities, or anyplace where people are at high risk for complications from the flu and are in close contact with each other.

Four antiviral medications are approved for treatment of the flu. They are: amantadine (Symmetrel), rimantadine (Flumadine), oseltamivir (Tamiflu), and zanamivir (Relenza).  Detailed information on each of the medications, including dosage and approved persons for use is also available at the CDC web site. See: http://www.cdc.gov/flu/professionals/treatment

For more information on this project, contact Ellen Lang, RN, MPH, in the Center for Medicare Advocacy’s Connecticut office: (860) 456-7790 or elang@medicareadvocacy.org