How are funding decisions made for Medicare and Medicaid? What drugs are to be funded? These questions have recently come to our attention as many of us have attempted to have Medicare fund our use of Provenge.
The administration of Medicare is actually broken into 15 different regions, or MACs (Medicare Administrative Contractors). Each MAC is responsible for deciding what treatments and drugs are to be reimbursed by Medicare. Initially, decisions are made at the MAC level, so it is possible that some MACs will approve a treatment or drug while others will not.
In some instants, the Federal organization, the Center for Medicare & Medicaid Services (CMS) , will step in and create a national policy for all the MACs. In the instances of funding for Provenge, CMS has just announced that it will be reviewing Provenge and eventually make a national policy decision on reimbursement. This process can easily take up to one year! In the mean time, CMS has instructed the MACs to continue to make individual regional decisions. So, until CMS provides a national guideline, some MACs will pay for Provenge, some may not pay and others will continue to make you jump through hoops to get it covered!
CMS has established a thirty day (30) (the month of July) public comment period for us the public to add our own “testimony”. I believe that a large public demand will help push an approval for all men who are on Medicare and who need Provenge to extend their life. Do not under estimate the power of numbers; take a lesson from the breast cancer community.