CMS Issues Positive Directive to Cover Anti-Epileptic Drugs Under Medicare Prescription Drug Benefit

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What's Happening with the new Medicare Prescription Drug Benefit?

The Epilepsy Foundation has been working with the Centers for Medicaid and Medicare Services (CMS) about the implementation for each phase of the new prescription drug benefit mandated by the Medicare Modernization Act. This is the fifth part in our Medicare updates with information about the Medicare prescription drug benefit.

CMS Issues Positive Directive to Cover Anti-Epileptic Drugs Under Medicare Prescription Drug Benefit

CMS has released encouraging news regarding the coverage of drugs in six classes (including anti-epileptic drugs) under the new Medicare Prescription Drug Benefit which begins January 1, 2006. Specifically, CMS has directed insurance plans that stated they must cover "all or substantially all" of the drugs in six classes that are often prescribed for Medicare beneficiaries including anti-convulsants, anti-depressants, anti-psychotics, anti-cancer, immunosuppressant and HIV/AIDS drugs.

CMS officials have said that after reviewing the Federal Employees Health Benefits Program, as well as Medicaid, the government made the determination that it was important to follow "best practices" in requiring a wide range of drugs so that beneficiaries will not experience any interrupted access to their therapy. Dr. Mark McClellan, CMS Administrator, stated: "We have a unique situation with the drug benefit this year. A lot of patients with serious illnesses have been stabilized on certain combinations of drugs and will transition into Medicare for their drug coverage. We want to give them access to all medically necessary treatments."

This is very good news, as is CMS' issuance of its previous guidance that it will review plans carefully to ensure that drugs used to treat the above conditions are covered. The open issue in implementation of the drug benefit and CMS' directive will be how coverage is actually provided by various insurers for antiepileptic drugs; to what extent will cost control measures such as prior authorization, preferences for certain drugs, or cost-tiering (more expensive drugs requiring greater beneficiary co-pays) occur and be permitted by CMS. The Epilepsy Foundation will continue to focus its efforts on ensuring that people have access to the medications their doctor prescribes at a reasonable cost, and that individuals are not effectively discriminated against by insurance plans because they have seizures.

It is reported that hundreds of insurers have filed applications with CMS to provide drug coverage. Since April of this year, plans have been submitting their proposed lists of drugs. However, in the last few weeks many plans have been making changes to their formularies in order to comply with CMS' stance on broad coverage for beneficiaries.

The final list of plans will be released to the public in October 2005. We will keep you informed in the following months through our weekly Medicare updates.

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