Case Flash: Part B Immunosuppressants Available
to Kidney Transplant Recipients

Mrs. H enrolled in Medicare Part A (inpatient/hospital insurance) in July 2000 and is enrolled in a Medicare private health plan. In March 2003, Mrs. H had a kidney transplant in a Medicare-certified facility to treat her End-Stage Renal Disease (ESRD) and had to start taking a self-administered immunosuppressive drug, CellCept, so that her body would not reject her new kidney. Mrs. H paid $50 for each fill of her prescription until November of 2008, when the pharmacy suddenly charged her $500. Not understanding why she suddenly had to pay so much money, Mrs. H called the Medicare Rights Center national hotline for help.

A hotline counselor helped Mrs. H call her Medicare private health plan to see why there was such a drastic change in her copayment. A representative of the plan, which also provides Mrs. H’s Medicare prescription drug coverage (Part D), told Mrs. H that she had entered the “doughnut hole” at the beginning of the month. In most Part D plans, once your total drug costs (both what you pay and what the plan pays for your drugs) reach a certain amount, you must pay the full cost for your prescriptions instead of a copayment. The representative said that was why she was suddenly paying so much more for her drug.

However, the Medicare Rights Center counselor told the representative that anti-rejection drugs that are self-administered after a Medicare-covered kidney transplant should be covered by Part B, not Part D. Because Part B has no “doughnut hole,” Mrs. H should still be paying $50 for her prescription, the private plan’s Part B copayment for that drug.

Mrs. H’s plan recognized that they had made a mistake and told Mrs. H that she could get reimbursed for the extra money that she paid for her prescription as long as she could submit her receipt to the plan, and that going forward she would pay only her Part B copayment.

-From “ Case Flash: Part B Immunosuppressants Available To Kidney Transplant Recipients”, Medicare Watch, a biweekly electronic newsletter of the Medicare Rights Center, Vol. 12 , No. 11: June 2, 2009.

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