Transcript PPT

2015 National Training Program
Medicare Prescription
Drug CoverageParts A, B and D
Session Objectives
 This session should help you
• Differentiate when/under what scenarios drugs are
covered under the various parts of Medicare

Part A vs. Part B vs. Part D
2
The Basics
 Medicare has 4 parts

A: Hospital coverage

B: Outpatient medical coverage

C: Medicare Advantage

D: Prescription Drug Coverage
Medicare Benefit Structure
Part A
Hospital
Insurance
Part B
Medical
Insurance
Part C
Medicare
Advantage
Plans (like
HMOs/PPOs)
Part D
Medicare
Prescription
Drug
Coverage
Includes Part A,
Part B, and
sometimes Part
D coverage
4
Medicare Prescription Drug Coverage
 Prescription drug coverage under Part A, Part B,
or Part D depends on
•
•
•
•
Medical necessity
Health care setting
Medical indication (why you need it the drug)
Any special drug coverage requirements
 This information applies if you have Original
Medicare
5
PART A
6
Part A Prescription Drug Coverage
 Part A generally pays for all drugs during a
covered inpatient stay
• Received as part of treatment in a hospital or
skilled nursing facility
 Drugs used in hospice care for symptom
control and pain relief only
7
PART B
8
Self-Administered Drugs in
Hospital Outpatient Settings
 Hospital
• Admission vs. Observation Status- Distinction is KEY!
 Part B doesn’t cover self-administered drugs in a
hospital outpatient setting
• Unless integral to the procedure or hospital service
 If enrolled in Part D, drugs may be covered
• If not admitted to hospital
• May have to pay and submit for reimbursement
9
Part B Prescription Drug Coverage
 Part B provides outpatient drug coverage in
limited situations
• Most injectable and infusible drugs given as part
of a doctor’s service
• Antigens administered for allergy testing
• Drugs and biologicals used for the treatment of
End-Stage Rena Disease
• Drugs which require use of Part B-covered durable
medical equipment (DME)
10
Part B
Part D
Medicare Part B vs. Part D
 Some drugs/drug classes may be covered by either Part
B or Part D depending on the situation
 Drug classes where such uncertainty exists:
• Insulin
• Vaccines

•
•
•
•
Hepatitis B vaccine
Immunosuppressants
Oral anti-cancer drugs
Oral anti-emetic drugs
Erythropoietin
Medicare Part B vs. Part D?
 BV is a 68 year-old beneficiary with type 1 diabetes, congestive
heart failure, and chronic pain. BV takes all of her medications orally
except her insulins; one of which she self-injects 5-10 minutes
before each meal and the other which she injects every evening. BV
presents her Medicare card which identifies that she has both
Medicare Parts A and B. She also shows a separate card which
shows that she has a Part D plan. BV gives both cards to the
pharmacy. Based on the above presented information, which part
of Medicare should the pharmacy bill for BV’s insulins?
 Answer: Medicare Part D; Medicare Part B covers external insulin
pumps and the insulin that the device uses under durable medical
equipment for people who meet certain conditions. Since BV does
not have a pump (this is evident by the fact that she self-injects
multiple times a day) the insulin would not be covered under Part B,
and thus her Part D plan should be billed.
Medicare Part B vs. Part D Coverage Determination
 Coverage category: Insulin
• Scenario: Beneficiary would like to fill their
insulin
• Community pharmacy setting billing:


Part B- Administered with an insulin pump
Part D- All other situations
Medicare Part B vs. Part D Coverage Determination
 Coverage category: Vaccines
• Scenario: Prophylactic Vaccines
• Community pharmacy setting billing:


Part B- flu, pneumococcal, and Hepatitis B*
(medium-high risk individuals) vaccines
Part D- for all other vaccines
Medicare Part B vs. Part D Coverage Determination
 Coverage category: Hepatitis B vaccine
• Scenario: Beneficiary would like to receive the
Hepatitis B vaccine series
• Community pharmacy setting billing:


Part B- Medium/High risk beneficiary
Part D- All other beneficiaries
Medicare Part B vs. Part D?
 GH is a 73 year-old beneficiary who has high blood pressure, high
cholesterol, diabetes, and a thyroid disorder. After consulting with
her health care provider, GH realizes that she needs to get the
Hepatitis B vaccine series. GH has both parts of Original Medicare
and a stand-alone prescription drug plan through Medicare.
 GH proceeds to go to her local pharmacy and indicates that she
would like the first dose of the Hepatitis B vaccine series. Based on
the above presented information, which part of Medicare should
the pharmacy bill for her first Hepatitis B vaccine dose?
 Answer: Medicare Part B; because GH has diabetes, which places
her in a “High Risk” category, the Hepatitis B vaccine series would
be covered under Medicare Part B.
Hepatitis B Risk Categories
 Intermediate risk groups
• Staff in institutions for the mentally handicapped
• Workers in health care professions who have frequent contact
with blood/blood-derived body fluids during routine work
 High risk:
• ESRD
• Hemophilia
• Clients of institutions for the mentally handicapped
• Those who live in the same household as a HBV carrier
• Homosexual men
• Illicit injectable drug abusers
• Diabetes
Medicare Part B vs. Part D?
 GH is an 82-year old beneficiary with autoimmune hepatitis. She
was recently prescribed the immunosuppressant prednisone to
help with her condition. GH has both parts of Original Medicare
and a stand-alone prescription drug plan (Part D). GH goes to the
pharmacy to get her prescription of prednisone filled. Based on
the above presented information, which part of Medicare should
the pharmacy bill for GH’s prednisone?
 Answer: Medicare Part D. Drugs used for immunosuppressive
therapy in a beneficiary that received a transplant from a
Medicare-approved facility would be billable to Medicare Part B,
but since that does not appear to be the case GH’s Part D plan
should be billed for her prednisone prescription.
Medicare Part B vs. Part D Coverage Determination
 Coverage category: Immunosuppressants
• Scenario: Drugs used for immunosuppressive therapy
in a beneficiary that received a transplant from a
Medicare-approved facility
• Community pharmacy setting billing:


Part B- for Medicare covered transplant
Part D- for all other situations
Medicare Part B vs. Part D Coverage Determination
 Coverage category: Oral chemotherapy agents
used in cancer treatment
• Scenario: Oral chemotherapy drugs for which there is
an infusible version of the drug
• Community pharmacy setting billing:


Part B- for cancer treatment
Part D- for all other indications
Medicare Part B vs. Part D Coverage Determination
 Coverage category: Oral anti-emetic drugs
• Scenario: Oral anti-nausea drugs used in cancer treatment as
replacement for IV anti-emetic drugs before, at, or within 48
hours of chemotherapy
• Community pharmacy setting billing:

Part B- within 48 hours of receiving chemo
NOTE: In order to bill Part B, CMS requires that the prescriber
indicate on the prescription that the oral anti-emetic is being
used “as full therapeutic replacement for an IV anti-emetic
drug as part of a CA chemotherapeutic regimen.”

Part D- for all other situations
Medicare Part B vs. Part D Coverage Determination
 Coverage category: Erythropoietin
• Scenario: Treatment of anemia for a person
with ESRD who is on dialysis
• Community pharmacy setting billing:


Part B- treatment of anemia for beneficiaries with
chronic renal failure undergoing dialysis
Part D- for all other situations
PART D
25
Prescription Drug Coverage
 Two ways to get outpatient prescription drug
coverage ‘through’ Medicare
1. Medicare Advantage Prescription Drug Plan (MA-PD)


‘Part C’
Bundles health & Rx coverage together
2. A stand-alone Prescription Drug Plan (PDP)
NOTE: A patient CANNOT add a PDP to an MA-PD
Part D Formulary Requirements
 Each plan will have its own formulary
• Each formulary must include all therapeutic
drug classes


Must cover a minimum of two agents from each
drug class
The two drug minimum must be met through the
provision of two chemically distinct drugs
 Plans must have an authorization process
for non-formulary medications
Protected Classes
(“Classes of Clinical Concerns”)
 All plans should cover all or substantially all of the
drugs in six therapeutic categories:
•
•
•
•
•
•
Antidepressants
Anticonvulsants
Antipsychotics
Antiretrovirals
Antineoplastics
Immunosuppressants
Medicare Part D Excluded List




Weight-loss or weight-gain
Fertility promotion
Cosmetic purposes/Hair growth
Erectile dysfunction used for treatment of sexual
dysfunction
 Products for cough/cold symptom relief
 Prescription vitamins/minerals
 OTC drugs
Medicare Part D Excluded Drugs
 Certain plans may cover these drugs as a
supplemental benefit to their plan.
• Not benchmark plans!
 However, any amount you spend for a drug in
one of these categories is not counted toward
any deductibles, initial coverage or out-ofpocket limits.
• Does not count towards TrOOP!
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