MEDICARE REPLACEMENT DRUG
THE DEMONSTRATION PROJECT: The
Medicare Modernization Act of 2003, authorized Medicare to pay for expensive
medications, not generally covered under Part B, for 50,000 of approximately
500,000 eligible Medicare beneficiaries. A “lottery” system was designed to
select which eligible beneficiaries would participate in the project.
ELIGIBLE MEDICARE BENEFICIARY: Any Medicare beneficiary with both Part A and B who is without comprehensive drug coverage under Medicaid, TriCare, or an employer plan. Also, Medicare beneficiaries with both Part A and B who have prescription drug coverage, but who have co-pays that are greater than the co-pays established under the demonstration project. The co-pay for individuals who are selected for the demonstration project is 25% of the cost of the medication.
VERY LOW ENROLLMENT: As of September 13, 2004, only 7,000 of the estimated 500,000 eligible Medicare beneficiaries had signed up to participate in the project.
CHANGE IN POLICY: As a result of low participation in the lottery, the lottery system was replaced with open enrollment on October 1, 2004. Applications will be accepted in the order in which they are received and coverage will begin on a “rolling” basis as applications are processed.
UPDATED LIST OF MEDICATIONS COVERED UNDER THE MEDICARE REPLACEMENT DRUG DEMONSTRATION PROJECT:
|Rheumatoid arthritis||Adalimumab (Humira)
|Psoriatic arthritis||Etanercept (Enbrel)|
repository corticotropin (H.P. Acthar Gel)
(patient must be homebound)
Calcitonin - nasal (Miacalcin
|Pulmonary hypertension||Bosentan (Tracleer)|
|Secondary hyperparathyroidism||Doxercalciferol (Hectoral)|
|Paget’s disease||Alendronate (Fosamax)|
|CMV retinitis||Valganciclovir (Valcyte)|
|Cutaneous T-cell lymphoma||Bexarotene (Targretin)|
|Non-small cell lung cancer||Gefitinib (Iressa)|
|Epithelial ovarian cancer||Altretamine (Haxalen)|
|Chronic myelogenous leukemia||Imatinib Mesylate (Gleevac)|
|GI stromal tumor||Imatinib Mesylate (Gleevac)|
|Multiple myeloma||Thalidomide (Thalomid)|
|Breast cancer||Hormonal therapy|
|Stage 2-4 breast cancer only||Anastrozole (Arimidex)
Tamoxifen (Nolvadex, Tamoxifen)
|Prophylactic agent to reduce Ifosfamide-induced hemorrhagic cystitis||Mesna (Mesnex)|
HOW TO SIGN-UP: Eligible Medicare beneficiaries should call 1-866-563-5386 (Trailblazer’s call center) or should visit www.medicare.gov.
Copyright © Center for Medicare Advocacy, Inc. 09/06/2013