2015 National Training Program

Medicare Prescription Drug Coverage- Parts 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

4

Part A Hospital

Insurance

Part B Medical

Insurance

Part C Medicare

Advantage Plans (like

HMOs/PPOs) Includes Part A,

Part B, and sometimes Part

D coverage

Part D Medicare

Prescription Drug

Coverage

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 A6

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 B8

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

Coverage Determination

Part B Part D

Part B vs. 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 D25

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-of-pocket limits.• Does not count towards TrOOP!

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