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

Module 8

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Session Topics

OverviewDrug coverage under Medicare Part ADrug coverage under Medicare Part BMedicare prescription drug coverage

Part D

Medicare parts A/B/D coordinationInformation sources

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Medicare Parts A, B, and D

Coverage under Part A, B, or D factorsHealth care setting

• For example, home or institutionMedical indication

• For example, cancerSpecial 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 planGet covered prescription drugs from the plan

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Part A Drug Coverage

Generally covers all drugs During a covered stayInpatients of hospitals or skilled nursing facilitiesReceiving 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 programMedicare Part A will pay

• Drugs for symptom control or pain reliefMedicare will not pay

• Drugs intended to cure the terminal illness In a Medicare drug plan

• Plan will pay for drugs unrelated to terminal illness

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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 Pharmacy/supplier must be participating DME

providerDrug must be medically necessary

• According to guidelines

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Part B Drug Coverage

Drugs administered through Part B-covered DMESuch as nebulizer or pumpOnly when used in conjunction with DME andIn patient’s home

Three categories of oral drugs with special coverage requirementsOral anti-cancer drugsOral anti-emetic drugsOral 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 of1)Aprepitant2)A 5-HT3 Antagonist3)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 Thiethylperazine Maleate 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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Entitled to Part A at time of transplant AND

Medicare paid for the transplant OR

Medicare was secondary payer but made no payment

Covered by Part B

Transplant conditions not met Part D may cover

Immunosuppressive Drug Coverage

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Immunosuppressive Drug Coverage—ESRD

Covered under Part BMedicare 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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Part D Definition of Part D covered drugs

Available only by prescription Used and sold in the United States Used for a medically accepted indication

Includes supplies associated with injection of insulin Syringes, needles, alcohol swabs, gauze

May cover if requirements under Part A or B not metImmunosuppressive drugs after an organ transplantSome oral anti-cancer drugsParenteral nutritionDrugs that are not usually self-administered

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Part D Coverage

“All or substantially all” drugs to treat certain conditionsCancer medicationsHIV/AIDS treatmentsAntidepressantsAntipsychotic medicationsAnticonvulsive treatments

• For epilepsy and other conditionsImmunosuppressants

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New in 2008Part D coverage of vaccinesAll drug plans must include

All commercially available vaccinesExcept those covered under Part B

Contact drug plan

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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 drugsUsually cover similar drugs

• Safe and effectiveMay have different 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 drugsTiersPrior authorizationStep therapyQuantity limits

Plans must have processes in placeMembers obtain medically necessary prescriptionsRequest coverage determinations and appeals

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Coverage Determination and Appeals Process

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Coverage Determination and Appeals Process (continued)

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Part D Coordination of Benefits

Medicare generally provides primary coverage for prescription drugsPart D plan pays first

Situations involving employer group health plan (EGHP)Part D plan denies primary claims

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Part D Coordination of Benefits

Medicare is secondary payer or

Plan does not know whether covered drug is related to an injury

Part D plans will always make conditional primary payment to ease burden on policyholder

Plan is aware that enrollee has workers’ compensation, Black Lung Program, or no-fault/liability coverage and has previously established that a certain drug is being used exclusively to treat a related injury

Part D plan will not pay

Non-EGHP situations

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Part A/B/D Determinations

Part D plan coverage determinationMay rely on information from physicians

• Should not replace plan’s processes for making coverage determination

Pharmacists’ help in determining Part D status• Explain how prior authorization requirements met

• Provide more information to plan

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Part A/B/D Conclusion

If payment could be available under Part A or BDrug will not be covered under Part D

• Even if a beneficiary has only Part A or Part BPayment considered available

• If person could choose to pay Part A and B premiums and deductibles

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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 Formwww.cms.hhs.gov/MLNProducts/Downloads/Form_

Exceptions_final.pdf

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Exercise

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

A. TrueB. False

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Exercise

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

A. TrueB. False

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Exercise

3. 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.

A. TrueB. False

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Exercise

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

A. TrueB. False

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Exercise

5. 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.

A. TrueB. False

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