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CMS Medicare Prescription Drug Formularies To Cover Nearly All HIV/AIDS-Related Medications
CMS in a document released on Friday said it is requiring Medicare prescription drug plans to cover "all or substantially all" drugs in six categories, including HIV/AIDS-related medications, CQ HealthBeat reports (CQ HealthBeat, 6/13). Medicare beneficiaries without existing prescription drug coverage will be able to enroll in the program beginning in November, with coverage beginning Jan. 1, 2006. Enrollment will remain open until May 2006, after which time beneficiaries wishing to enroll will have to pay higher fees. Under the final rules, the average beneficiary enrolling in the prescription drug plan will pay an estimated $35 in monthly premiums, as well as a $250 annual deductible. Medicare will cover 75% of the next $2,000 in prescription drug expenses. After that, beneficiaries will pay full drug expenses until their total annual expenditures reach $5,100. Medicare will cover 95% of drug costs after that point (Kaiser Daily HIV/AIDS Report, 3/15). Health insurance plans cannot use techniques such as prior authorization or step therapy to manage drug costs in the HIV/AIDS category, according to the CMS document. However, insurance plans can require physicians to obtain prior authorization before prescribing the injectable antiretroviral drug Fuzeon, CMS said (CQ HealthBeat, 6/13). North Carolina-based biotechnology firm Trimeris and Swiss drug maker Roche jointly developed Fuzeon, which is in a class of drugs called fusion inhibitors and is designed for HIV/AIDS patients who have failed to respond to other medications. The drug has encountered resistance from doctors and patients because of its high cost -- about $20,000 per patient annually -- and twice daily injection delivery method (Kaiser Daily HIV/AIDS Report, 3/14). Any drugs in the six categories that are approved for marketing after Jan. 1 will be subject to review by a plan's "pharmacy and therapeutics committee" to decide whether they will be covered, the agency said. In addition, CMS said it will revisit the drug formularies for the six categories for 2007 (CQ HealthBeat, 6/13).
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