Medicare Parts B/D Coverage Issues - Centers for Medicare ...

1 Medicare Parts B/D Coverage Issues This table provides a quick and easy reference guide for the most frequent B/D Coverage determination scenarios facing Part D plans and Part D pharmacy providers. It does not address all potential situations. For more extensive discussion, please refer to the Medicare Part B vs. Part D Coverage Issues document available at: Part B Coverage Part B Coverage Retail and Home LTC Pharmacy Comments Categories Description Infusion Setting Pharmacy B/D Coverage Setting B/D Coverage Durable Medical Drugs that require Part B Part D Blood Glucose Testing Equipment (DME) administration via covered Because most LTC Strips and Lancets covered Supply Drugs DME ( inhalation facilities are not under Part B DME benefit NOTE: Only drugs, IV drugs requiring 2 considered a are never available under available for a pump for infusion, insulin beneficiary's home 4 Part D because they are beneficiaries via infusion pump)3 not Part D drugs.

2 Residing in their home 1. Drugs furnished Injectable/ Part D Part D Part D plans should not incident to a Intravenous drugs 1) Because by definition a Because by definition a implement pharmacy edits physician service administered incident to a pharmacy cannot pharmacy cannot provide to determine B vs. D. physician service and 2) provide a drug incident a drug incident to a Coverage for injectable/IV. considered by Part B to a physician's service physician's service (Only drugs only covered under carrier as not usually self- (Only a physician office a physician office would Part B when furnished administered . would bill Part B for bill Part B for incident to incident to a physician incident to drugs). drugs). service. 1. In addition to a hospital, a SNF or a distinct part SNF, the following LTC facilities cannot be considered a home for purposes of receiving the Medicare Part B.

3 DME benefit: A nursing home that is dually-certified as both a Medicare SNF and a Medicaid nursing facility (NF). A Medicaid-only NF that primarily furnishes skilled care;. A non-participating nursing home ( neither Medicare nor Medicaid) that provides primarily skilled care; and An institution which has a distinct part SNF and which also primarily furnishes skilled care. 2. The DMERCs determines whether or not an IV drug requires a pump for infusion. 3. The DMERCs do a medically necessity determination with regard to whether a nebulizer or infusion pump is medically necessary for a specific drug /condition. 4. If a facility does not meet the criteria in footnote 1, it would be considered a home, and Part B could cover the drugs. 1. Medicare Parts B/D Coverage Issues This table provides a quick and easy reference guide for the most frequent B/D Coverage determination scenarios facing Part D plans and Part D pharmacy providers.

4 It does not address all potential situations. For more extensive discussion, please refer to the Medicare Part B vs. Part D Coverage Issues document available at: Part B Coverage Part B Coverage Retail and Home LTC Pharmacy Comments Categories Description Infusion Setting Pharmacy B/D Coverage Setting B/D Coverage Immunosuppressant Drugs used in B or D: B or D: Participating Part B. Drugs immunosuppressive Part B for Medicare Part B for Medicare pharmacies must bill the therapy for beneficiaries Covered Transplant Covered Transplant DMERC in their region that received transplant when these drugs are from Medicare approved Part D for all other Part D for all other covered under Part B. facility and were entitled to situations situations Medicare Part A at time of transplant ( Medicare Covered Transplant ).

5 Oral Anti-Cancer Oral drugs used for cancer B or D: B or D: Participating Part B. Drugs treatment that contain pharmacies must bill the same active ingredient (or Part B for cancer Part B for cancer DMERC in their region pro- drug ) as injectable treatment treatment when these drugs are dosage forms that would covered under Part B. be covered as 1) not Part D for all other Part D for all other usually self administered indications indications and 2) provided incident to a physician's service Oral Anti-emetic Oral anti-emetic drugs B or D: B or D: Participating Part B. Drugs used as full therapeutic Part B within 48 hrs of Part B within 48 hrs of pharmacies must bill the replacement for IV anti- chemo chemo DMERC in their region emetic drugs within 48 hrs when these drugs are of chemo Part D all other Part D all other situations covered under Part B.

6 Situations 2. Medicare Parts B/D Coverage Issues This table provides a quick and easy reference guide for the most frequent B/D Coverage determination scenarios facing Part D plans and Part D pharmacy providers. It does not address all potential situations. For more extensive discussion, please refer to the Medicare Part B vs. Part D Coverage Issues document available at: Part B Coverage Part B Coverage Retail and Home LTC Pharmacy Comments Categories Description Infusion Setting Pharmacy B/D Coverage Setting B/D Coverage Erythropoietin (EPO) Treatment of anemia for B or D: B or D: EPO may be covered person with chronic renal Part B for treatment of Part B for treatment of under Part B incident to . failure who are undergoing anemia for beneficiaries anemia for beneficiaries physician's service for dialysis undergoing dialysis undergoing dialysis other indications but a pharmacy would not be Part D all other Part D all other situations billing for incident to drugs situations Prophylactic Influenza; B or D: B or D: Vaccines given directly Vaccines Pneumococcal; and Part B for Influenza, Part B for influenza, related to the treatment of Hepatitis B (for Pneumococcal, & pneumococcal, & an injury or direct exposure intermediate to high risk Hepatitis B ( for Hepatitis B (for to a disease or condition beneficiaries).))

7 Intermediate to high intermediate to high risk) are always covered under risk) Part B. Part D for all others Part D for all others Parenteral Nutrition Prosthetic benefit for B or D: B or D: Part D does not pay for the individuals with Part B if permanent Part B if permanent equipment/supplies and permanent dysfunction of dysfunction of digestive dysfunction of digestive professional services the digestive tract. If tract tract associated with the medical record, including provision of parenteral the judgment or the Part D for all other Part D for all other nutrition or other Part D. attending physician, situations situations covered infusion therapy. indicates that the impairment will be long and indefinite duration, the test of permanence is met. 3.