From: J Manarite
Subject: Re: [Prostatecanceraction] Trailblazers (Medicare) & Provenge
To: "ProstateCancer Action"
Date: Thursday, July 29, 2010, 12:01 PM


I've been trying to do my homework on this, so here's what I know about Trailblazers - Correct me if I'm Wrong -
First of all, remember there are 2 separate Medicare/Provenge issues happening right now. One is the CMS (national Medicare) which the Public Comment is part of. This process is called an NCA or an NCD, and onces it is started, will take close to a year to be complete. This is not the Traiblazer issue.

- - - - - - - - - -
So, here's the Trailblazers issue. While CMS is conducting their NCA, the local/state Medicare Carriers (MAC's) can pay for Provenge. It looks like this:

10 different MAC's, (only 3 have written policies covering Provenge - 7 do not. Traiblazers is one of the 7.)
15 different jurisdictions covering (only 5 have written policies covering Provenge - 10 do not.)
50 states + D.C. + 5 US territories (only 12 states + 2 US territories have written policies covering Provenge)
plus a little bit of arm wrestling in the court system over which MAC has which jurisdiction

So, here is what Traiblazers' jurisdiction currently looks like (to the best of my knowledge)

* Jurisdiction 4 (J4)- Trailblazers Health Enterprises - Colorado, New Mexico, Oklahoma, Texas

* Jurisdiction 11 (J11) - North Carolina, Virginia - Currently Trailblazers Health Enterprises, but Awarded to Palmetto GBA? - (dependent on expected Sept court ruling)

I think the take-home message is that advocates in CO, NM, OK, TX, NC, SC, VA, and WV might get together and start communications with Trailblazers.

correction (from Scott Riccio@ Dendreon) - SC and WV are NOT Trailbalzers for Medicare part B. They are Palmetto, so they are getting Provenge paid for. Good news.

At this point, we are not only advocating for the patients, we are advocating for and with the physicians. Think about the key physicians in the Trailblazer states that have their hands tied re: Provenge reimbursement. Here's one - E David Crawford posted today on Public Comment. Plus - Provenge PI's - Dr Logothetis, Dr Schellhammer - somebody add names, because I know there's more.

I am working on Florida.
Jan Manarite
PCRI Florida Educational Facilitator
(239) 395-0995










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From: kmeadelist@aec225.com
To: prostatecanceraction@malecare.com
Date: Wed, 28 Jul 2010 23:12:49 -0400
Subject: Re: [Prostatecanceraction] Medicare & Provenge - an update or 2


I was just told by the wife of a patient in New Mexico that Trailblazer has said they will not pay for Provenge and they were told by the doctor today that he can’t get Medicare/Trailblazer to pay for Jevtana for prostate cancer. She is very upset because these were his last treatment options.





Kathy





From: prostatecanceraction-bounces@malecare.com [mailto:prostatecanceraction-bounces@malecare.com] On Behalf Of J Manarite
Sent: Thursday, July 22, 2010 6:40 PM
To: ProstateCancer Action
Subject: [Prostatecanceraction] Medicare & Provenge - an update or 2

First of all, the CMS public comment (part of a national process that will take almost a year) is a separate issue than the individual Medicare Carrier decisions (which can happen now). So, here's what I've learned.

- - - - - - - -
*Current Status -
Individual Medicare Carriers & their states (Jurisdictions)
Provenge Policy IN WRITING? (when)

Jurisdiction 1 (J1) Palmetto GBA- American Samoa, California, Guam, Hawaii, Nevada, Northern Mariana Islands - YES (May '10)Jurisdiction 2 (J2)- Alaska, Idaho, Oregon, Washington - Awarded to National Heritage Insurance Company - ? (Jim Kiefert may know more)
Jurisdiction 3 (J3)- Noridian Administrative Services -Arizona, Montana, North Dakota, South Dakota, Utah, Wyoming - NO
Jurisdiction 4 (J4)- Trailblazers Health Enterprises - Colorado, New Mexico, Oklahoma, Texas - NO
Jurisdiction 5 (J5)-Wisconsin Physician Services Health Insurance Corporation- Iowa, Kansas, Missouri, Nebraska - NO
Jurisdiction 6 (J6) - Illinois, Minnesota, Wisconsin- Awarded to Noridian Administrative Services * -NO
Jurisdiction 7 (J7) - Arkansas, Louisiana, Mississippi - Awarded to Pinnacle Business Solutions Inc.* -NO
Jurisdiction 8 (J8) - Indiana, Michigan - Awarded to National Government Servces * - NO
Jurisdiction 9 (J9)-First Coast Service Options-Florida, Puerto Rico, United States Virgin Islands - NO
Jurisdiction 10 (J10) -Cahaba Government Services -Alabama, Georgia, Tennessee - NO
Jurisdiction 11 (J11)-North Carolina, South Carolina, Virginia, West Virginia - Awarded to Palmetto GBA? - not yet, but YES (dependent on expected Sept court ruling)
Jurisdiction 12 (J12)-Highmark Medicare Services -Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania -NO
Jurisdiction 13 (J13)-National Government Services -Connecticut, New York - YES (July '10)
LINK: http://www.ngsmedicare.com/sia/ARTICLE%20%20Sipuleucel_T_ProvengeRelatedtoLCDL25820_A50060.htm
Jurisdiction 14 (J14) - National Heritage Insurance Company - Maine, Massachusetts, New Hampshire - NO
Jurisdiction 15 (J15) -Kentucky, Ohio- Awarded to Highmark Medicare Services * - NO