Accessing the Medicare Demonstration Program
When Medicare first began, drugs played a much smaller role in medical care. Until now, only drugs that are administered in a physician's office have been covered. The Medicare Replacement Drug Demonstration is a time-limited demonstration that will provide a special "bridge" benefit to cover certain self-administered biologics that are prescribed as replacements for existing, (infusible) medicines currently covered by Medicare part B.
The purpose of this demonstration is to provide these medicines before Medicare's prescription drug plan (part D) begins in January 2006. and to provide a cost analysis of providing self-injectibles versus in-office administered drugs.
This demonstration allows up to 50,000 people with Medicare who have either RA or Osteoporosis to obtain specified drugs they can take themselves at home. These medicines include:
| Demonstration Covered Indication | Drug/ Biologic |
|---|---|
| Rheumatoid Arthritis | Adalimumab (Humira), Etanercept (Enbrel), Anakinra (Kineret) |
| Ankylosing Spondylitis | Etanercept (Enbrel) |
| Psoriatic Arthritis | Etanercept (Enbrel) |
| Osteoporosis (patient must be homebound) | Calcitonin - nasal (Miacalcin - nasal) |
In order for a beneficiary to be eligible for this demonstration, he or she must meet the following criteria:
- Beneficiary must have Medicare Part A and Part B
- Medicare must be the beneficiary's primary health insurance.
- Beneficiary must reside in one of the 50 states or the District of Columbia .
- Beneficiary may not have any other insurance that has comprehensive drug coverage (such as Medicaid, an employer or union group health plan, or TRICARE) that would cover this medication.
- Beneficiary must have a signed document from his/her doctor, which will serve as a prescription (included in the application documents).
Note: Both Fee-for-Service and Medicare Advantage beneficiaries are eligible to apply for the demonstration.
Expenses Involved
Medicare will assign patients to one of five different benefit levels. The standard benefit level, "Benefit Level ONE," will include the following out-of-pocket expenses for the patient:
- An annual deductible of $250
- A total out-of-pocket limit of $3,600
- Once this total of $3,600 is reached, the patient will pay the greater of a monthly 5% or $5.00 co-pay
The bulk of these expenses tend to be front-loaded and spread out over the first five months of therapy.
Four other benefit levels will range from a flat 15% co-pay on the high end to virtually nothing on the low end.
Companies that provide the covered drugs have also designed multiple financial assistance programs for Medicare patients with these expenses.
Note: The demonstration is not the Medicare Prescription Drug Program that will begin in 2006.
The demonstration program will end on December 31, 2005. To continue to obtain these Medicare-covered drugs after this date, patients will need to join a Medicare prescription drug plan in 2006. Please share this information with your Medicare beneficiary patients who would be both eligible and interested in participating. To obtain an application, your patients can call (866) 563-5386.
Logistics
The Center for Medicare Services (CMS), has contracted with Caremark to administer the drug benefit under this demonstration. Once patients are enrolled, they will receive a demonstration-specific drug coverage card. They can then fill their prescriptions through a local neighborhood pharmacy that participates in Caremark's nationwide network or utilize mail order delivery to their home through Caremark's specialty pharmacy program. Approximately 98% of all local pharmacies participate in Caremark's network.
In order for a beneficiary to be eligable, egence’s new policy involves Humira, one of the biologic TNF inhibitors. Their pharmacy committee has declared this a second-line agent and is requiring patients to have failed other biologic agents before having this option. No data exist that would make this a second-line agent. Because each agent is unique and has select advantages, patients will suffer if they are required to fail another TNF agent first (see Position Statement on New Agents for Arthritis on biological agents at the American College of Rheumatology web site www.rheumatology.org/publications/position/dmard.asp ).