CMS Clarifies Medicare Coverage of Injectable Medicines

CMS on May 15 clarified its position on Medicare coverage of injectable drugs, stating that such medications should be covered if beneficiaries self-administer them less than 50% of the time, the Wall Street Journal reports. The clarification came in a memo to the regional private contractors that process Medicare claims and instructed them to reimburse users of the multiple sclerosis drug Avonex because it generally is not self-administered. The clarification, which takes effect Aug. 1 and "could cause carriers to add or drop coverage of other injectable drugs," aims to resolve ambiguity in CMS' policy on reimbursing injectable drugs (Lueck, Wall Street Journal, 5/16). Until now, Medicare has paid only for injectable drugs administered in a doctor's office, but not drugs that patients administer themselves, such as insulin. Last year, however, Congress said that Medicare should cover self-injected drugs that are "not usually self-administered," but failed to define "not usually." The imprecise language led Medicare contractors to make different reimbursement decisions for the same drug (Kaiser Daily Health Policy Report, 4/12). The memo, the Journal reports, "is part of a continuing effort by CMS to standardize the decisions of contractors, which have broad discretion to make their own determinations" (Wall Street Journal, 5/16). The memo "will bring more consistent coverage policy for outpatient drugs across the country," CMS Administrator Tom Scully said in a release (Bloomberg News/Boston Globe, 5/16).

'What Congress Directed Us to Do'
Under the clarification, only Medicare beneficiaries going to a doctor's office for an Avonex injection once a week are eligible for reimbursement. Medicare will not cover three other injectable drugs commonly prescribed to people with MS -- Rebif by Serono SA, Capaxone by Teva Pharmaceutical Industries and Betaseron by Berlex Laboratories and Chiron Corp. CMS informed contractors that such drugs usually are administered by patients themselves and thus should not be covered, the Journal reports. Avonex, on the other hand, is injected "deep into the muscle" -- considered a difficult procedure -- and CMS instructed contractors to "presume patients aren't doing [the injection] themselves." A survey by the drug's maker, Biogen, found that Avonex users usually do not administer the injection themselves, but rather another individual, such as a relative, administers it. Scully said, "Th[is] may not be the soundest health policy in the long run, but that's what Congress directed us to do." CMS intends to ask for public comment on the new policy (Wall Street Journal, 5/16).