On June 24 the U.S. Department of Health & Human Services (HHS) announced a new Medicare demonstration program that will allow a limited number beneficiaries who have serious diseases such as cancer, multiple sclerosis, pulmonary hypertension and rheumatoid arthritis to join a prototype of Medicare part D.

Under this initiative, Medicare will partially pay for certain drugs and biologicals that can be taken by the patient at home and that replace drugs which are currently covered under Medicare Part B when given in a doctor's office. In addition, newer, more effective medications that replace some currently covered oral anti-cancer drugs will also be covered. Beneficiaries will save 55 to 90% of what it might cost them to purchase these drugs from a pharmacy over the course of the year. Lower income beneficiaries who qualify for a reduced level of out-of-pocket cost sharing will usually save almost 90 percent. The more expensive a drug, the greater the percentage of savings to beneficiaries. Those who face the highest expenses get the highest benefit.

Beneficiary cost sharing for these drugs will mirror the "standard" Medicare Part D prescription drug benefit when it is implemented in 2006 (participants will not pay the monthly premium in the demonstration, however). Beneficiaries with limited resources and incomes of less than 150 percent of the federal poverty level (FPL) will have even lower cost sharing requirements. For those between 100 and 135 percent of the FPL, they would pay at most $60 per year for any of the drugs covered in the demonstration program, and seniors below 100 percent of FPL could pay less.

As directed by Congress in creation of the demonstration, approximately 40 percent of the funding will be allocated for oral anti-cancer medications. If more beneficiaries apply than Medicare is able to serve, the Centers for Medicare & Medicaid Services (CMS) will select participants among the cancer and non-cancer groups randomly from the applications received, on an alternating basis between the two groups.

Participants in the demonstration will be able to get their drugs at a local retail pharmacy or by home delivery. CMS' demonstration contractor is TrailBlazer Health Enterprises. Mail order prescriptions will be available through Caremark, Trailblazer's subcontractor for administering the drug benefit.

The demonstration will run through Dec. 31, 2005, at which time all beneficiaries will be able to enroll in the new Medicare Part D drug benefit.

Eligibility:

• Must be enrolled in Medicare Part A and Part B,
• Medicare must the be primary payer,
• No other comprehensive drug coverage (such as TriCare, Medicaid, or an employer or union sponsored plan).
• Must also have a signed certification from a doctor that the beneficiary requires one of the drugs covered under the demonstration for the indicated disease.

To Enroll, Beneficiaries Should:

• complete an application, (www.cms.hhs.gov/researchers/demos/drugcoveragedemo.asp).
• get physician to complete the required form certifying the need for the covered drug,
• and submit both forms to CMS' demonstration contrac-tor, TrailBlazer Health Enterprises.

Applications received by Aug. 16 will be in an "early selection" process that will give them coverage by Sept. 1. The application deadline is September 30, 2004 unless enrollment slots are still available. As long as the application is received by Sept.30, all applicants will have an equal chance to get into the demonstration.

Between now and July 6, beneficiaries who have questions can call 1-800-MEDICARE. Starting July 6, customer service representatives will be available at 1-866-563-5386, TTY Number: 1-866-536-5387 to answer questions about the demonstration and assist beneficiaries in obtaining and completing the application forms.

For more information please go to the demonstration main page: www.cms.hhs.gov/researchers/demos/drugcoveragedemo.asp.

Brochure for patients (includes list of covered drugs): www.cms.hhs.gov/researchers/demos/01_MRDD_pamphlet.pdf.

- Adapted from U.S. Department of Health & Human Services press release, www.hhs.gov/news/press/2004pres/20040624.html.

06/2004