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Expanded Medicare Coverage of Immunosuppressive Drugs for Kidney Transplant Recipients

In December 2020, the law was changed to provide lifetime Medicare coverage of immunosuppressive drugs for kidney transplant recipients. Before this, people who were eligible for Medicare only because of end-stage kidney failure (not because of age or disability), lost coverage for their immunosuppressive medications 36 months post-transplant. Many patients struggled to pay for these drugs, leading to rationing or stopping taking the medications entirely, either of which almost always resulted in the transplant failing and the patient returning to dialysis. Many others did not even try to get a transplant for fear of not being able to afford their immunosuppressive drugs 36 months after their transplant. Now, anyone who meets the criteria will qualify for lifetime Medicare coverage of their immunosuppressive drugs, regardless of age.

Who is eligible for the indefinite coverage?

Anyone who meets the following criteria are eligible for indefinite coverage of their transplant immunosuppressive medications under Medicare Part B:

  • Received a kidney transplant from a Medicare-approved facility.
  • Was eligible for Medicare at the time of their transplant and applied for Medicare prior to the transplant (even if they were not enrolled at that time). It does not matter if Medicare was the primary or secondary payer to other insurance.
  • Does not have Medicaid.
  • Does not have other public or private health insurance with an immunosuppressive benefit.

Public insurance includes Medicaid, Department of Veterans Affairs coverage, or TRICARE (for civilian Armed Forces personnel and retirees). Private insurance examples include a group health plan (HMO, PPO), employer-based plan, coverage under the Affordable Care Act, or individual health insurance plan.

When will I be able to get the extended immunosuppressive coverage?

Coverage will become effective on January 1, 2023. The Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) will develop an enrollment program prior to this date. We will provide updates as they become available.

We recognize the immediate need for access to medications for many patients whose coverage will expire before January 2023. We will continue to work with pharmaceutical companies, state assistance programs and others to prevent gaps in coverage. If you are having trouble affording your medications, contact our NKF Cares Helpline for assistance: 855.653.2273 or nkfcares@kidney.org.

If my coverage expires prior to January 1, 2023, will I be eligible?

Yes. Anyone who had a transplant and whose Medicare eligibility expires before, on, or after January 1, 2023 can enroll in Medicare Part B solely for immunosuppressive coverage if they do not have other insurance for their immunosuppressive drugs. The enrollment period for anyone whose Medicare coverage ends prior to January 1, 2023 begins on October 1, 2022.

What actions will I be required to take to enroll?

You will have to apply to determine whether you meet the necessary requirements (see above). The application process is not yet available, but we will provide an update once it is.

I have Medicare and Medicaid. Do I qualify for the indefinite Medicare immunosuppressive coverage?

No. Your immunosuppressive medications will be covered by your state’s Medicaid plan, if you maintain that insurance coverage. If you lose both traditional Medicare and Medicaid coverage, you can apply for the Medicare immunosuppressive coverage.

What if I am eligible for the new benefit but I later obtain coverage that includes immunosuppressive coverage?

You will be required to notify the Social Security Administration (SSA) within 60 days of enrollment in your new coverage.

Will I continue to have other Medicare covered benefits 36 months after transplant?

No. All other Medicare benefits for kidney recipients who are under 65 and not eligible for Medicare based on a disability would still end three years (36 months) after the transplant.

Are other transplant related medications covered under the extension?

No, only immunosuppressive drugs are covered indefinitely.

Will I be charged the full Part B monthly premium that I currently pay?

No. Since your Medicare coverage after 36 months is limited to immunosuppressive drugs, the monthly premium will be equal to 15 percent of the monthly rate for Medicare beneficiaries age 65 and over. The amount will be determined by the U.S. Department of Health and Human Services (HHS) in September of each year.

Will I be required to pay the standard 20% copay under Medicare Part B?

We don’t know yet; however, we expect to find out before the January 1, 2023 effective date and will provide an update as soon as available.

Will the extension be limited to specific immunosuppressive drugs, or to generics?

No. Since effectiveness of immunosuppressive drug regimens for kidney recipients can differ among patients, your transplant physician will continue to prescribe the regimen most beneficial for you.

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Date Reviewed: 02-05-2021