Magazine article Drug Topics

New Medicare Self-Injectable Policy Still Seen as Wanting

Magazine article Drug Topics

New Medicare Self-Injectable Policy Still Seen as Wanting

Article excerpt


A new program memorandum intended to clarify federal policy Ion Medicare payments for injectable drugs administered outside of hospitals has left some patient groups thankful and others feeling shortchanged. The mid-May memorandum, from the Centers for Medicare & Medicaid Services (CMS), outlined in broad strokes its interpretation of the December 2000 Benefits Improvement & Protection Act (BIPA), which was meant to increase Medicare coverage of drugs injected in doctors' offices or outpatient clinics.

Congress tried to do just that by broadening the law's language to include payment for drugs that are "not usually selfadministered," where previously Medicare had covered only drugs that "cannot be selfadministered." The subtle change in the lawmakers' intent was apparently too vague, causing Medicare contractors around the country to interpret the language inconsistently, sometimes denying coverage to frail elderly patients unable to self-inject.

Gary Stein, Ph.D., director of federal regulatory affairs at ASHP, said he was "disappointed" by the CMS program memorandum. "When I attended the town hall meeting a couple of years ago on this issue, we were hoping for a little bit more liberal coverage," he said. "This does not seem to do that. I think there are very few drugs that are going to be covered under this, and it's going to put patients at harm."

One drug that will be covered is interferon beta 1a (Avonex), the medication commonly used to treat relapsing forms of multiple sclerosis. CMS mentioned the drug in a press release it issued when it announced the program memorandum. It specified no other drugs, though CMS anticipates that new drugs in the pipeline will qualify for payment under the new standards. CMS expects that the new rule will cost $100 million in the first year, compared with the $150 million that Congress envisioned when it passed BIPA.

A spokesman for the federal healthcare program said CMS had singled out the MS drug "simply because there's so much interest in it, and it's going to be the biggest chunk." But he also said that Medicare carriers would continue to have leeway in deciding coverage. The program memorandum was issued, he said, to give carriers "some guidance in making their individual drug-by-drug decisions. It doesn't name [the drugs]. Interferon is just an assumption we're making. We're not saying they have to, just that we expect them to."

One reason interferon made the grade was that it is administered by intramuscular injection. CMS assumes that drugs delivered IM or intravenously are "not usually selfadministered," while those that are given subcutaneously are more likely to be self-injected by patients. …

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