So just what is the Medicare lottery? It is the system devised to implement the Medicare Re­placement Drug Demonstration that will cover some oral drugs before Medicare’s comprehensive prescrip­tion drug program began in 2006.

This lottery is a temporary bridge for qualified people until the comprehensive program begins. Seniors and people with disabilities could save substantial money by participating. For GIST patients, the oral cancer drug Gleevec will be covered.

The Medicare Replacement Drug Demonstration is limited to 50,000 people or $500 million, whichever comes first. The selection into the lottery will be random from the pool of applicants, alternating between cancer patients and others with seri­ous diseases. Applications for the lottery will be accepted until Sept. 30. Completed applications received by Aug. 16 will be in the first draw­ing, with coverage starting Sept. 1.

A second drawing will take place after the Sept. 30 deadline. Applicants not chosen in the first drawing will be included in the second draw­ing. For those picked in the second lottery, coverage takes effect Oct. 18.

Trail Blazer, a subsidiary of Blue Cross and Blue Shield, will manage this demonstration. Caremark is the pharmacy that will be providing the drug benefit to patients.

The requirements to be eligible for the lottery (demonstration) are:

  • Be able to obtain Medicare Part A and have Medicare Part B
  • Have Medicare as primary insurance
  • Live in one of the 50 states or the District of Columbia
  •  Have a signed document from your doctor explaining that you need one of the drugs covered under this demonstration for your health condition (you currently don’t need to be taking one of the drugs to qualify)
  • Not have any other insurance that has comprehensive drug cover­age such as Medicaid, employer or union group health plan or Tricare

Patients will pay an annual premium and various co-pays. For the first full year 2005, patients will be responsible for the first $250 in drug expenses, and will pay an average of 25 percent co-insurance until they reach the benefit limit of $2,250. After reaching this limit, patients will face a gap in coverage (the so-called “doughnut hole”) in which they will pay all of their drug costs up to $5,100 in total drug spending. The total out-of-pocket cost at this point is $3,600. Medicare will then cover 95 percent of drug costs above that amount. Some low-income patients whose incomes are 135 to 150 per­cent of the federal poverty level will have a reduced deductible.

The following table shows what happens to a patient who takes $30,000 worth of Gleevec per year.

You pay

Medicare pays

The first $250:

$250 ($100%)

0

The next $2,000:

$500 (75%)

$1,500 (25%)

The next $2,850:

(the “doughnut hole”)

$2 ,850 (100%)

0

The next $24,900:

$1,245 (5%)

$23,655 (95%)

Subtotal:

$4,845 (16%)

$25,155 (84%)

Your annual premium:

$420

0

Grand Total:

$5,265 (18%)

$25,155 (82%)

For those currently enrolled in the Novartis Assistance Program who qualify for the lottery, Novartis will help with the out-of-pocket expenses. If you don’t qualify, Novartis will continue your assistance as before.

To apply and or obtain any information regarding this lottery, please call 866-563-5386 (Monday-Friday, 8 a. m.-7:30 p.m. EST) or go to www.medicare.gov and click on “Medicare to Extend Access to Certain Drugs For Beneficiaries with Serious and Chronic Illness.” You will be able to download the application from there.

The doctor’s portion of the application must be completed or your application will not be processed.

Click Here For a Medicare Lottery Application