Attorneys

• Rebecca L. Burke
• Mary Susan Philp

Medicare Part B v. Part D Drug Coverage Issues

Drugs for which coverage is available under Medicare Part A or Part B are excluded from coverage under Medicare Part D.  Medicare Part A payments to hospitals and skilled nursing facilities generally cover all drugs provided during a stay.  Part B coverage of drugs is usually limited to drugs or biologicals administered by infusion or injection; if an injection is generally self-administered, it is not covered under Part B.

Although Part B coverage of outpatient drugs is limited, because it is available under some circumstances, questions may arise as to whether Part B or Part D applies.  In general, the answer may depend on (1) the characteristics of the beneficiary; (2) the medical use of the drug; (3) the form of the drug; or (4) whether the drug is furnished in the context of another service.  It should also be noted that non-coverage of a drug under Part B does not necessarily mean that it is covered under Part D, as Part D plan formularies vary.

The following are some of the common situations where the Part B v. Part D issue arises:

• Immunosuppressant Drugs: Covered under Part B for post-transplant patients if transplant was covered by Medicare; if transplant was not Medicare-covered or if for non-transplant-related indications, coverage would be under Part D.

• Injectable/intravenous drugs administered in health care facility: Covered under Part B; this would include most chemotherapy drugs, allergy shots, and other drugs that cannot be self-administered.

• Oral Anti-Cancer Drugs:Covered under Part B for cancer treatment; covered under Part D for other indications.

• Oral Anti-emetic Drugs: Covered under Part B within 48 hours of chemotherapy; covered under Part D for other indications.

• Erythropoietin(EPO): Covered under Part B for treatment of anemia for beneficiaries undergoing dialysis; covered under Part D for all other indications.

• Preventive Vaccines:  Influenza and pneumococcal vaccines are covered under Part B; Hepatitis B vaccine is covered under Part B for individuals who are at high or intermediate risk; other vaccines may be covered under Part D.

• Parenteral Nutrition: Covered under Part B for individuals with permanent dysfunction of the digestive tract; covered under Part D for other indications.

• Infusible DME supply drugs – Covered under Part B if administered in the patient’s home using an infusion pump; covered under Part D if administered by another method, such IV push or drip.

• Intravenous immune globulin (IVIG) – Covered under Part B if the diagnosis is primary immune deficiency disease; covered under Part D for other diagnoses.

• Inhalation DME supply drugs – Covered under Part B when used with a nebulizer in the home; covered under Part D if delivered with a metered dose inhaler or other non-nebulized administration.

For additional information, contact Susan Philp or Rebecca Burke or call 202.466.6550.