Medicare Watch

Legislation Introduced to Expand Access to Part D Coverage

On Thursday, July 15, U.S. Representatives Mary Jo Kilroy (D-OH) and Mac Thornberry (R-TX) announced the introduction of the bipartisan Part D Off-Label Prescription Parity Act (H.R. 5732). The bill allows Medicare to cover prescriptions used for off-label indications when such use is supported by peer-reviewed medical literature, as is the case under Part B and for Part D cancer drugs. Currently, under Part D, for medications used to treat conditions other than cancer, Medicare will not cover drugs used for off-label indications if they are not listed in statutorily identified compendia, privately owned and published drug guides. The legislation brings Part D rules in line with other parts of the Medicare program, and expands treatment options by allowing coverage of safe and effective drugs based on the most up-to-date published medical literature.

The Medicare Rights Center has followed this issue closely since the implementation of Part D in 2006, and continues to receive calls on its Part D Appeals hotline from consumers who are unable to access medically necessary drugs used for off-label indications. In addition to working toward a legislative remedy, Medicare Rights has challenged in federal court the regulations that govern Medicare coverage of off-label drug treatments.

Read our letter of support.

Read the press release.

Proposed Changes to Part B Income-Related Premiums to Help Those Affected by the Economy

Due to the recent changes in the economic climate, the Social Security Administration (SSA), through an interim final rule released today, is expanding its definition of a “life-changing event” that creates exceptions to individuals’ obligations to pay increased Part B premiums if they have high incomes. For example, companies that have closed or reorganized may provide one-time payouts or settlements to retirees instead of pensions. The interim final rule would excuse such one-time increases in income from the Part B premium calculation if an affected consumer provides evidence of such a settlement. Other companies have had to reorganize or terminate pension programs altogether. The interim final rule clarifies that Part B premium calculations should reflect these changes to an affected individual’s income if he or she is able to provide proper evidence.

In 2010, people with Medicare who have annual incomes above $85,000 ($170,000 for couples) are considered to have higher incomes, and pay higher Part B premiums. For these individuals, premium amounts are based on a tiered scale correlating to income. In order to determine if a consumer owes a higher premium, SSA consults tax filings for the two to three years prior to the year when Part B premium obligations are assessed.

While the interim final rule is effective today, July 15, 2010, SSA will accept comments until September 13, 2010.

Read the interim final rule.

Read more on income-related Part B premiums.

Medicare Reminder

Sometimes a Medicare drug plan refuses to cover a drug that is on its list of covered drugs (also known as a formulary). There are two possible reasons for this:

1. The drug is subject to coverage restrictions such as prior authorization, quantity limits or step therapy.
2. Your doctor prescribed the drug for a reason other than the use approved by the U.S. Food and Drug Administration. This is known as off-label use.

To make sure you take the correct action, you should know why your plan is denying you coverage and get the reason in writing.

Learn more about coverage restrictions and off-label use on MedicareInteractive.org.

Spotlight

Medicare Rights Center President Joe Baker is taking questions on Medicare on the New York Times’s Bucks blog.

Read the questions, and submit one of your own.

Read Joe Baker’s answers.