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

Medicare Drug Coverage
Under Part A, Part B
and Part D
Module 8
Session Topics
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Overview
Drug coverage under Medicare Part A
Drug coverage under Medicare Part B
Medicare Prescription Drug Coverage—Part D
Medicare Parts A/B/D Coordination
Information Sources
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Medicare Parts A, B, and D
 Determining if coverage is under Part A, B, or D
– What is the health care setting
• e.g., home, hospital, surgery center or institution
– What is the medical indication
• e.g., to treat cancer
– Are there special coverage requirements
• e.g., those for immunosuppressive drugs
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Parts A and B Coverage
in Original Medicare
 Parts A and B
– Cover some drugs in certain situations
– Generally don’t cover outpatient drugs
• Most are now covered under Part D
 For Medicare coverage under Parts A, B, or D
– Drugs must be medically necessary
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Part A Drug Coverage
 Generally covers all drugs during a covered stay
– Hospital or skilled nursing facility (SNF)
– Receiving drugs as part of treatment
 Part B can pay for some Part B covered drugs in
hospitals and SNFs
– If you don’t have Part A or your coverage has run out
– The stay is not covered by Part A
 Part D may pay for formulary drugs
– If not admitted
– May have to pay and submit for reimbursement
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Drug Coverage for Hospice Care
 When receiving Medicare-covered hospice care
– Part A
• Covers drugs for symptom control or pain relief
• Will not cover drugs to cure the terminal illness
– Part D
• May pay for drugs to treat conditions unrelated to the
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
– Administered through Part B-covered Durable Medical
Equipment (DME)
– Some other types of drugs
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Part B Drug Coverage DME Drugs
 Drugs administered through Part B-covered DME
– Such as nebulizers and pumps
– Only when used with DME in patient’s home
 Supplier must be DME provider
– In some areas must be contract provider
– Ask if supplier is accredited
 Drug must be medically necessary
– According to guidelines
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Part B Drug Coverage – Certain Oral Drugs
 Oral drugs with special coverage requirements
– Anti-cancer drugs
– Anti-emetic drugs
– Immunosuppressive drugs, under certain circumstances
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Oral Anticancer Drugs*
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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*
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Azathioprine-oral
Azathioprine-parenteral
Cyclophosphamide-Oral
Cyclosporine-Oral
Cyclosporine-Parenteral
Daclizumab-Parenteral
Lymphocyte Immune
Globulin, Antithymocyte
Globulin-Parenteral
 Methotrexate-Oral
 Methylprednisolone-Oral
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 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 Drugs (continued)
If You
Are entitled to Part A at time of
transplant
and
Medicare paid for your transplant
or
Medicare was secondary payer but
made no payment
Did not meet the transplant conditions
above
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Your Immunosuppressive
Drugs
Are covered by Part B
–Medicare pays 80%
–Patient pays 20%
–Do not count toward
catastrophic coverage
under Part D
 May be covered by Part D
–Costs vary by plan
 Helps cover drugs needed
for other conditions
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Hospital Outpatient Settings
 Part B doesn’t cover “self-administered drugs”
– Unless required for the hospital outpatient services
 Part D may cover these drugs
– If requirements under Part A or Part B are not met
– You may need to pay up front
• 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-covered Drugs
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Prescription brand-name and generic drugs
Approved by FDA
Used and sold in U.S.
Used for medically-accepted indications
Include drugs, biologicals, and insulin
– Supplies associated with injection or inhalation
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Required Coverage
 “All” drugs in 6 categories
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Health
Reform
Section
3307
Cancer medications
HIV/AIDS treatments
Antidepressants
Antipsychotic medications
Anticonvulsive treatments for epilepsy and other conditions
Immunosuppressants
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Vaccines
 All Part D drug plans must cover
– All commercially available vaccines (e.g., shingles
vaccine)
– Except those covered under Part B (e.g., flu shot)
 Contact drug plan for more information
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Drugs Not Covered by Part D
 Excluded by law from Medicare coverage
– Anorexia, weight loss or weight gain drugs
– Barbiturates and benzodiazepines*
– Erectile dysfunction drugs when used for the treatment of
sexual or erectile dysfunction
– Fertility drugs
– Drugs for cosmetic or lifestyle purposes (e.g., hair growth)
– Drugs for symptomatic relief of coughs and colds
– Prescription vitamin and mineral products (except
prenatal vitamins and fluoride preparations)
– Non-prescription drugs
*To be covered in 2013
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Your Rights
 Plan doesn’t cover a drug or
 Drug cost higher than you think you should pay
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Follow plan’s process to request coverage determination
Ask for an exception (a type of coverage determination)
You can appeal if request is denied
Pharmacist will explain how to contact your drug plan
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Part D Coverage Determinations
 Part D plan coverage determination
– May rely on information from physicians
• Should not replace plan’s process
– Pharmacists help in determining Part D status
• Explain prior authorization requirements
• Provide more information to plan
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Part D Exception Requests
 Two types of exceptions
– Tiers
• e.g., getting Tier 2 drug at Tier 1 cost
– Formulary
• Drug not on plan’s formulary or
• Access requirements
 Requests can be made only by you, your
appointed representative, or the prescriber
 Requires supporting statement from physician
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Levels of Appeal
Redetermination with the Part D
plan (sponsor)
Reconsideration with the
independent review entity
Hearing with an administrative
law judge
Review by the Medicare Appeals
Council
Review by a federal district court
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Part D Coordination of Benefits
Employer Group Health Plan (EGHP) Situations
Under this Circumstance
If Medicare is primary and your EGHP prescription drug
coverage is secondary
If your EGHP prescription drug coverage is primary
This applies if you :
–Are age 65 or over with EGHP based on current
employment of self or spouse (firm with 20 or more
employees)
–Have Medicare based on a disability with EGHP (firm
with 100 or more employees)
–Have Medicare based on ESRD during the 30-month
coordination period with EGHP and firm is any size
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Medicare Drug Coverage Under Part A, Part B and Part D
Part D Plans
Generally pay
first
Deny primary
claims
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Part D Coordination of Benefits
Non-Employer Group Health Plan Situations
Under this Circumstance
If the plan is aware that an 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 Plans
Will not pay primary
In all other instances (i.e., plan does
not know whether covered drug is
related to an injury)
Will always make conditional
primary payment to ease
burden on the policyholder
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Exercise
A. Most outpatient drugs are covered under
Medicare Part A.
1. True
2. 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.
1. True
2. False
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For More Information…
 Contact your Medicare drug plan
 Read the Medicare & You handbook - CMS Pub. # 10050
 Visit “Compare Medicare Prescription Drug Plans” at
www.medicare.gov
 Read Your Guide to Medicare Prescription Drug Coverage –
CMS Pub. # 11109
 Call your State Health Insurance Assistance Program
 Call 1-800-MEDICARE (TTY users should call 1-877-4862048)
 For forms, e.g., a Request for Coverage Determination, visit
http://www.cms.hhs.gov/MedPrescriptDrugApplGriev/13_
Forms.asp
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