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 enrollmenton October1, 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 LISTOF 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) |
| Post menopausal osteoporosis (patient must be homebound) |
Calcitonin – nasal (Miacalcin–nasal, Salmonine) |
| Pulmonary hypertension | Bosentan (Tracleer) |
| Secondary hyperparathyroidism | Doxercalciferol (Hectoral) |
| Paget’s disease | Alendronate (Fosamax) |
| Hepatitis C |
Peginterferon alfa-2a(Pegasys) |
| 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 reduceIfosfamide-induced hemorrhagiccystitis | 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.