Coverage gap for anti-rejection drugs puts transplant patients at risk

An April 2 story in the New York Times highlighted a potentially dangerous insurance coverage gap faced by heart transplant patients and recipients of other organs—the immunosuppressive drugs they need to prevent organ rejection sometimes aren’t covered by Medicare if they received the transplants before enrolling in the program.

The American Society of Transplantation described the coverage gap as “an emerging and alarming problem,” according to the Times. David Roe, MD, medical director of the lung transplant program at Indiana University Health, called it a “life-threatening problem.”

Patients receiving kidneys usually have little problem getting the expensive drugs, the Times explained, because most of them are on Medicare with dialysis before their transplants and the drugs were most widely tested in this group.

But even though physicians have found the therapies serve the same function in patients receiving other organs—most of whom are younger and insured outside of Medicare when they get new organs—the medications weren’t tested as thoroughly in those populations and the drugs aren’t officially approved in Medicare’s Part D program. So, the commercial insurers involved in Medicare Part D aren’t required to pay for these drugs, and hospitals and physicians struggle to help patients when their prescriptions are denied.

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