MEDICARE REPLACEMENT DRUG
DEMONSTRATION UPDATE


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:

DISEASE   COVERED MEDICATIONS
Rheumatoid arthritis Adalimumab (Humira)
Anakinra (Kineret)
Etanercept (Enbrel)
Psoriatic arthritis Etanercept (Enbrel)
Multiple sclerosis 

repository corticotropin (H.P. Acthar Gel)
Glatiramer acetate (Copaxone)
Interferon beta-1a (Rebif, Avonex)
Interferon beta-1b (Betaseron)

Post menopausal osteoporosis
(patient must be homebound)

Calcitonin - nasal (Miacalcin nasal, Salmonine)
Risedronate (Actonel)

Pulmonary hypertension Bosentan (Tracleer)
Secondary hyperparathyroidism Doxercalciferol (Hectoral)
Paget’s disease Alendronate (Fosamax)
Hepatitis C

Peginterferon alfa-2a (Pegasys)
Peginterferon alfa-2b (PEG-Intron)

CMV retinitis Valganciclovir (Valcyte)
Acromegaly Pegvisomant (Somavert)
Anti-Cancer            
     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)
Exemestane (Aromasin)
Letrozole (Famara)
Tamoxifen (Nolvadex, Tamoxifen)
Toremifene (Fareston) 
Prophylactic agent to reduce Ifosfamide-induced hemorrhagic cystitis Mesna (Mesnex)
Psoriasis etanercept (Enbrel)
efalizumab (Raptiva)

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