Medicare Drug Coverage Under Part A, Part B, and Part D

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Medicare Drug Coverage Under Part A, Part B, and
Part D
Module 8
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Session Topics

• Overview
• Drug coverage under Medicare Part A
• Drug coverage under Medicare Part B
• Medicare prescription drug coveragePart D
• Medicare parts A/B/D coordination
• Information sources

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Medicare Parts A, B, and D

• Coverage under Part A, B, or D factors
• Health care setting
• For example, home or institution
• Medical indication
• For example, cancer
• Special coverage requirements
• For example, those for immunosuppressive drugs

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Part A and B Drug Coverage

• Parts A and B generally do not cover outpatient
  drugs
• Most outpatient drugs are covered under Part D
• Parts A and B cover drugs in particular
  situations
• All requirements must be met
• Drug must be medically necessary
• People with MA Plan with drug coverage
• Get all Medicare-covered health care from the
  plan
• Get covered prescription drugs from the plan

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Part A Drug Coverage

• Generally covers all drugs
• During a covered stay
• Inpatients of hospitals or skilled nursing
  facilities
• Receiving drugs as part of treatment
• Part B can pay hospitals and SNFs
• Person does not have Part A coverage
• Part A coverage for the stay has run out
• Stay is not covered

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Medicare Hospice Benefits

• In Medicare-approved hospice program
• Medicare Part A will pay
• Drugs for symptom control or pain relief
• Medicare Part A will not pay
• Drugs intended to cure the terminal illness
• In a Medicare Part D drug plan
• Plan may pay for drugs not covered by Part A

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Part B Drug Coverage

• Part B covers a limited set of outpatient drugs
• Injectable and infusible drugs
• Not usually self-administered
• Furnished and administered as part of a physician
  service
• Some other types of drugs

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Part B Drug Coverage

• Oral drugs or DME drugs covered by Part B
• Supplier must be DME provider
• Drug must be medically necessary
• According to guidelines

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Part B Drug Coverage

• Drugs administered through Part B-covered DME
• Such as nebulizer or pump
• Only when used with DME in patients home
• Oral drugs with special coverage requirements
• Anti-cancer drugs
• Anti-emetic drugs
• Immunosuppressive drugs
• And other non-oral forms

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Oral Anticancer Drugs

• Busulfan
• Capecitabine
• Cyclophosphamide
• Etoposide
• Melphalan
• Methotrexate
• Temozolomide

List is subject to change
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Oral Anti-emetics Prescribed for Use Within 48
Hours of Chemotherapy

• 3 oral drug combination of
• Aprepitant
• A 5-HT3 Antagonist
• Dexamethasone
• Chlorpromazine Hydrochloride
• Diphenhydramine Hydrochloride
• Dolasetron Mesylate (within 24 hours)
• Dronabinol

• Granisetron Hydrochloride (within 24 hours)
• Hydroxyzine Pamoate
• Ondansetron Hydrochloride
• Nabilone
• Perphenazine
• Prochlorperazine Maleate
• Promethazine Hydrochloride
• Trimethobenzamide Hydrochloride

List is subject to change
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Immunosuppressive Drugs

• Azathioprine-oral
• Azathioprine-parenteral
• Cyclophosphamide-Oral
• Cyclosporine-Oral
• Cyclosporine-Parenteral
• Daclizumab-Parenteral
• Lymphocyte Immune Globulin, Antithymocyte
  Globulin-Parenteral
• Methotrexate-Oral
• Methylprednisolone-Oral

• Methylprednisolone Sodium Succinate Injection
• Muromonab-Cd3-Parenteral
• Mycophenolate Acid-Oral
• Mycophenolate Mofetil-Oral
• Prednisolone-Oral
• Prednisone-Oral
• Sirolimus-Oral
• Tacrolimus-Oral
• Tacrolimus-Parenteral

List is subject to change
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Immunosuppressive Drug Coverage
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Immunosuppressive Drug Coverage ESRD

• Covered under Part B
• Medicare pays 80
• Patient pays 20
• Will not count toward catastrophic under Part D
• Part D
• Pays for immunosuppressive drugs
• If conditions for Part B coverage not met
• Helps pay for drugs needed for other conditions

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Hospital Outpatient Settings

• Part B doesnt cover Self-administered drugs
• Unless required for the hospital outpatient
  services
• Part D may cover if requirements under Part A or
  Part B not met
• May need to pay up front/out-of-pocket
• Submit the claim to Part D plan for refund
• Check with the hospital to see if it participates
  in Part D

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Part D

• Coverage of Part D covered drugs
• Includes supplies associated with injection of
  insulin
• May cover certain drugs if requirements under
  Part A or Part B are not met

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Part D Coverage

• All or substantially all drugs to treat
  certain conditions
• Cancer medications
• HIV/AIDS treatments
• Antidepressants
• Antipsychotic medications
• Anticonvulsive treatments
• For epilepsy and other conditions
• Immunosuppressants

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Vaccines

• Part D coverage of vaccines
• All drug plans must include
• All commercially available vaccines
• Except those covered under Part B
• Contact drug plan for information

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Excluded Drugs

• Drugs for anorexia, weight loss, or weight gain
• Fertility drugs
• Drugs for cosmetic purposes or hair growth
• Cough and cold medicine
• Prescription vitamins
• Except prenatal and fluoride preparations
• Nonprescription drugs (over-the-counter drugs)
• Barbiturates
• Benzodiazepines
• Erectile dysfunction drugs

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Coverage Varies

• Plans have formularies
• May not include all outpatient drugs
• Usually cover similar drugs
• Safe and effective
• May have different cost levels (tiers)
• Choosing generic drugs can save money
• People can get treatment they need

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Access to Covered Drugs

• Plans can manage access to covered drugs
• Tiers
• Prior authorization
• Step therapy
• Quantity limits
• Plans must have processes in place
• Members obtain medically necessary prescriptions
• Request coverage determinations and appeals

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Coverage Determination and Appeals Process
Part D
IRE Independent Review Entity MA-PD Medicare
Advantage plan that offers Part D benefits PDP
Prescription Drug Plan
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Coverage Determination and Appeals ProcessPart
D (continued)
AIC Amount in controversy ALJ Administrative
Law Judge
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Part D Coordination of Benefits

• Medicare generally provides primary coverage for
  prescription drugs
• Part D plan pays first
• If employer group health plan is primary
• Part D plan denies primary claims

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Part D Coordination of Benefits
Non-Employer Group Health Plan Situations
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Part D Determinations

• Part D plan coverage determination
• May rely on information from physicians
• Should not replace plans process
• Pharmacists help in determining Part D status
• Explain prior authorization requirements
• Provide more information to plan

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Part A/B/D Conclusion

• If payment is available under Part A or B
• Drug will not be covered under Part D
• Even if a person has only Part A or only Part B
• Payment considered available
• If person could choose to pay Part A and B
  premiums and deductibles

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Exercise

• A. Most outpatient drugs are covered under
  Medicare Part A.

• True
• False

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Exercise

• B. Medicare Part A payments made to hospitals
  and Skilled Nursing Facilities generally cover
  all drugs provided during a stay.

• True
• False

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Exercise

• C. Part B can pay hospitals and Skilled Nursing
  Facilities for certain categories of Part B
  covered drugs if a person does not have Part A
  coverage.

• True
• False

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Exercise

• D. In Medicare-approved hospice program
  Medicare Part A will not pay for drugs for
  symptom control or pain relief.

• True
• False

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Exercise

• E. If payment for a drug could be available to
  an individual under Part A or Part B, then it
  will not be covered under Part D.

• True
• False

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For More Information

• Medicare Drug Coverage
• Medicare.gov
• Search Tools
• Find out what Medicare Covers or
• Compare Medicare Prescription Drug Plans
• Medicare Part D Coverage Determination Request
  Form
• http//www.cms.hhs.gov/MLNProducts/Downloads/Form_
  Exceptions_final.pdf

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