understanding medicare coverages
DESCRIPTION
Medicare now has four parts to it. Understand what it covers and what you can do to protect yourself from what it does not cover in full.TRANSCRIPT
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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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