DOH Medicaid Update June 2006 Special Edition

Office of Medicaid Management
DOH Medicaid Update
June 2006 Special Edition

 

State of New York
George E. Pataki, Governor

Department of Health
Antonia C. Novello, M.D., M.P.H., Dr. P.H.
Commissioner

Medicaid Update
is a monthly publication of the
New York State Department of Health,
Office of Medicaid Management

Brian Wing, Deputy Commissioner

 


Medicare Part D Prescription Drug Program
June 2006 Special Edition!

Please Read and Save for Future Reference
Return to Table of Contents

This special edition of the Medicaid Update provides updated, detailed information regarding the impact of Medicare Part D on Medicaid providers and full benefit dual eligible recipients (recipients with both Medicare and Medicaid services).

RX

In this edition, we want to specifically draw your attention to changes in the Medicaid wrap-around program. Then, there is important information that can help you help your patients maximize their drug benefit through the exception, appeal, and prior authorization process. "Transition to Medicare Part D" discusses the role of the prescriber, pharmacist, and recipient when transitioning to a new, or different, Medicare Part D plan.

Check summaries of key issues such as enrollment and co-payments. We also have included detailed information about the differences in drug coverage under Medicare Part B and Part D, which should help assure your patient has quick and easy access to their medication through the appropriate Medicare plan.

You may want to keep this MEDICAID UPDATE handy to use as a general reference when helping your patients maximize their Medicare drug benefit.

The information provided in this edition is also available on the Department's website at:
http://www.nyhealth.gov/health_care/medicaid/program/medicaid_transition/index.htm


PLEASE NOTE THE FOLLOWING CHANGES TO THE MEDICAID
WRAP-AROUND PROGRAM AS A RESULT OF NEWLY PASSED LEGISLATION
Return to Table of Contents

Limited Medicaid Wrap-around benefit for those with Medicaid and Medicare:

As you are aware, on January 1, 2006, Medicare Part D became the source of prescription coverage for those recipients with both Medicare and Medicaid. NYS Medicaid continues to cover certain drugs which are excluded from the Part D benefit, such as barbiturates, benzodiazepines, some prescription vitamins, and some non-prescription drugs.

NYS Medicaid also provides a "wrap-around" program which covers medications that are included in the Part D benefit when the recipient is unable to receive them from their Part D plan.

Effective July 1, 2006, drugs which are covered through this Medicaid wrap-around benefit will be limited to the following four categories of drugs:

  • Atypical antipsychotics
  • Antidepressants
  • Antiretrovirals used in the treatment of HIV/AIDS
  • Anti-rejection drugs used in the treatment of tissue and organ transplants

Medicare Part D is the primary payor for dual eligibles, and should provide access to all medically appropriate medications through the coverage determination and appeal process. It is anticipated that the Medicaid wraparound benefit will be used for the four classes of drugs when:

  • these drugs are not covered by the specific plan,
  • the patient does not meet the plan's utilization management requirements; or
  • there are quantity limits inconsistent with the prescribed amount.

The wrap-around program cannot be used to obtain:

  • early refills,
  • refills for lost or stolen drugs,
  • extended or vacation supplies.

Changes to the MVS Requirements

Providers were notified in December 2005 that they must obtain a denial from Medicare Part D, and complete a Medicare Verification System (MVS) process, prior to payment by Medicaid under the wrap-around benefit. This requirement has been discontinued. However, prescribers are still expected to work with their patient's Medicare Part D plans to maximize their patient's Medicare drug benefit.

How will the limited wrap-around benefit work?

When the recipient presents their prescription to the pharmacist, the pharmacist must first complete all the following necessary CMS procedures to assure Medicare Part D coverage. When these procedures are attempted, and coverage by Part D has failed, the pharmacist may dispense the medication to the recipient and submit a claim to Medicaid.

All Medicaid rules apply to these claims, including billing any other available third party insurance. If the drug requires prior authorization by Medicaid, the prescriber and pharmacist must complete the PA process for duals by calling 1-877-309-9493.

Procedure for Billing Medicare

Pharmacists are to use the following processes when experiencing difficulty with their patients' Medicare plan enrollment, cost sharing, or payment:

  1. Check for enrollment in a Part D plan, by asking for a plan ID card or other documentation from a Part D plan, or, submit an E1 query. If the E1 response is only a telephone number, call that telephone number to obtain the billing information from the plan. Pharmacists can also get information on a beneficiary's enrollment, and on how to contact the plan, by calling Medicare's dedicated pharmacy assistance line (1-866-835-7595), which is available 24/7. This number is to be used only by pharmacists.
  2. If the individual is enrolled in a plan, but is not being charged the correct dual-eligible co-payment amounts, contact the drug plan (which has expedited access for pharmacy requests to adjust co-payments). If the situation is urgent and other steps have not worked, contact Medicare's pharmacy assistance line for urgent caseworker assistance for the beneficiary.
  3. If there is no evidence of a Part D plan enrollment but there is clear evidence of both Medicare and Medicaid eligibility (for example, a Medicare card and a Medicaid card or prior history of Medicaid prescription coverage at the pharmacy), bill the POS Contractor (WellPoint) for the claim. The pharmacist can also call the dedicated pharmacy assistance line to confirm that the beneficiary is in Medicare.

Procedure for Billing Medicaid

After completing all necessary CMS procedures to assure Medicare Part D coverage, the pharmacist may submit a claim to Medicaid.

The claim MUST include the following additional information, which verifies that the pharmacist has attempted, and failed to bill Medicare, in order to receive payment approval:

  1. A value of '2' (Override) in the Eligibility Clarification Code - Field 309-C9
  2. A value of '03' (Other coverage, Claim not covered) in the Other Coverage Code - Field 308-C8
  3. A value of '07' (Medicare Approved) in the Other Payer Amount Paid Qualifier - Field 342-HC
  4. A value of '0.00' (dollar amount) in the Other Payer Amount Paid - Field 431-DV

Note: If your billing system does not allow for the entry of the '07' qualifier and the '0.00' dollar amount in fields 342-HC and 431-DV, it is acceptable to leave them blank.


Exceptions, Coverage Determinations, and Appeals
Return to Table of Contents

Pen

Although there may be certain restrictions on the use of particular drugs, all medically necessary drugs must be available under the Medicare prescription drug plan benefit, whether or not they are on the plan's formulary. Drug plans must provide an exception and appeal process for drugs not on the formulary. This process cannot be utilized for drugs excluded from Medicare Part D coverage.

Prescribers have a choice whether to use drugs on the plan's formulary and select a formulary drug that does not require prior authorization. In these cases, the prescriber writes the prescription which is then filled at the pharmacy. No further action is needed. However, if it is medically necessary that their patient have a non-formulary drug, or a drug that requires prior authorization, then the prescriber must seek an exception request or prior authorization from the patient's plan.

The Medicare Part D drug benefit includes rights and protections to ensure beneficiaries have access to medically necessary treatments not included on a plan's formulary or that require prior authorization. Plans must have procedures to ensure access to medically necessary drugs.

Prescribing physicians have an important role in this process. Whenever a medically necessary drug is not on the formulary or requires prior authorization, the prescribing physician may be required to provide the Part D plan with an oral or written statement to support the request. Formulary exception requests also include requests for exceptions to utilization management tools, such as step therapy or dose restrictions.

The recipient, their appointed representative, or the prescriber can request an exception or appeal. An exception is also called an initial coverage determination. We encourage prescribers to assume this role. A recipient can designate anyone as their appointed representative by completing the form provided by CMS called Appointment of Representative, Form #1696. The form can be found on the CMS website at http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf. A copy of this form can be found in the Appendix.

Requesting an Exception or Prior Authorization

  • Contact the drug plan-they will advise:
    • How to submit a request
    • What information to submit-prescriber must submit supporting statement and must demonstrate the requested drug is medically necessary
  • After receiving prescriber's statement, the plan must notify enrollee of its decision within
    • 72 hours for a standard exception request
    • 24 hours for a expedited exception request

A simplified, standardized exception form was designed to assist prescribers in applying for exceptions and prior authorizations on behalf of Medicare beneficiaries regardless of which Medicare drug plan a beneficiary is enrolled in. The Medicare Part D Coverage Determination Request Form is available at the CMS website, on the Provider Center page under "Part D Tools for Health Care Professionals," http://www.cms.hhs.gov/center/provider.asp. A copy of the form is also found in the Appendix.
If the exception is approved, the exception applies to the initial fill and refills and may extend beyond the initial prescription, depending on the plan.

If the exception request results in a denial, plans are required to complete and issue a "Notice of Denial of Medicare Prescription Drug Coverage" to the recipient, and their prescriber, every time the plan denies an exception request/coverage determination. This form is labeled "Form No. CMS-10146," in the lower left hand corner. Please be sure to keep a copy of this denial notice in the patient's record.

Appeals

A person can appeal a drug plan's unfavorable exception or prior authorization decision. There are five levels of appeals, with the first level appeal made to the plan, generally done in writing by the recipient or an appointed representative. Expedited appeals take only a few days. Plans must provide this information to beneficiaries upon enrollment. CMS describes this process in the "Physician Part D Resource Fact Sheet," which explains the exception and appeal process and provides a glossary of terms to help recipients, providers and pharmacists better understand this process. This fact sheet can also be found on the CMS website at: http://www.cms.hhs.gov/MLNProducts/downloads/Part_D_Resource_Fact_sheet_revised.pdf. A copy is also provided in the Appendix.

The five levels of appeals in sequence include:

  1. Redetermination by the Part D plan sponsor
    • Expedited requests may be made orally or in writing; standard requests must be made in writing
    • The enrollee must be notified of the decision no later than 72 hours after receiving an expedited request, or 7 days after receiving a standard request
    • If a plan does not make a redetermination within the applicable timeframe, the request must be forwarded to the independent review entity for review
    • Unfavorable decisions are appealable to the Independent Review Entity (IRE)
  2. Reconsideration by the IRE
    • Expedited and standard requests must be made in writing
    • The enrollee must be notified of the decision no later than 72 hours after receiving an expedited request, or 7 days after receiving a standard request
    • Unfavorable decisions are appealable to the Department of Health and Human Services (DHHS)
  3. Hearing with a DHHS Administrative Law Judge (ALJ)
    • Hearing requests must be in writing
    • Unfavorable ALJ decisions are appealable to the Medicare Appeals Council (MAC)
  4. Review by the MAC
    • Review requests must be in writing
    • Unfavorable decisions are appealable to the federal district court
  5. Review by a federal district court
    • Enrollee must file a civil action in federal district court

The prescriber, the recipient, or their appointed representative should continue the appeal process to get the recipient's drug covered by their plan when an exception or prior authorization is denied. The prescriber, recipient, or their appointed representative should contact the plan to determine how to proceed with the appeal process. The plan denial letter should include all information necessary to continue this process.


Transition to Medicare Part D
Return to Table of Contents

Transition is a very important time for you and your patient. Transition assures timely access to a temporary supply of non-formulary drugs while the prescriber reviews their patient's drug regimen and either changes their drug therapy to a therapeutically appropriate formulary alternative or requests a formulary exception or prior authorization based on medical necessity.

Transition is a Time for Action!

Phone

When is a person in transition?

  • When they enroll in a new prescription drug plan
  • When they change their Part D plan to another Part D plan
  • When they change from another drug plan to a Part D plan
  • When they change their setting of care (for example, from a hospital to a home or institutional setting).

What does the transition apply to?

  • Transition process requirements apply to formulary and non-formulary drugs, meaning both:
    • Part D drugs that are not on a plan's formulary, and
    • Part D drugs that are on a plan's formulary but require prior authorization or step therapy under a plan's utilization management rules.

What's the recipient's role in transition?

  • Recipients are encouraged to choose a plan that best meets their needs. They may need help checking with their plans for information on drug coverage and any drug utilization requirements such as prior authorization or step therapy. Recipients should contact their drug plan to ask for a written explanation about why a prescription is not covered or to ask for an exception if they believe they need a drug that is not on their drug plan's formulary. Recipients should work with their prescribers to assure medically necessary drugs are covered by the Part D plan. If a recipient chooses to change plans, they should be encouraged to do so at the beginning of the month (before the 10 th ). Enrollments early in the month give Medicare and the drug plans time to update their systems, and mail important information, such as a welcome package and a membership card before their coverage becomes effective.

What's the prescriber's role in transition?

  • Prescribers are encouraged to take action to ensure that recipients will continue with their necessary drug regimen. This may entail switching a recipient to a covered formulary drug or initiating step therapy, if appropriate, or obtaining an exception authorization through the plan. This also entails a prescriber to seek prior authorization for a specific drug, if required by the plan.

What's the pharmacist's role?

  • Pharmacists are encouraged to pay attention to any special messaging they may receive through the claims processing system. Pharmacists should alert their patients and their prescribers when the prescription is non-formulary or requires prior authorization.

    Standardized electronic messages have been developed to help pharmacists quickly determine the appropriate course of action for filing beneficiaries' prescriptions under four different circumstances:
    • When a particular drug is not covered;
    • When prior authorization is required;
    • When plan quantity or other coverage limitations have been exceeded; or
    • When the pharmacy is not part of the Part D plan's network.
  • Pharmacists may be asked by the recipient to assist them with the transition process. The pharmacist must post and should have available for enrollees the "Medicare Prescription Drug Coverage and Your Rights" notice, providing information about contacting an enrollee's Part D plan to obtain a written coverage determination. A copy of this notice is found in the Appendix.

What's the plan's role in transition?

  • Plans have a responsibility to assure enrollees' appropriate transition to formulary drugs and to make timely determinations on enrollees' exceptions, appeals, and prior authorization requests.

Note: CMS has instructed plans that they must give special attention to recipients already stabilized on drugs so that there is no gap in coverage in the following six classes: antidepressant, antipsychotic, anticonvulsant, anticancer, immunosuppressant and HIV/AIDS.


Medicare and the Dual Eligible - Some of the Basics
Return to Table of Contents

What Does The Medicare Drug Benefit Look Like?

The Medicare prescription drug benefit is provided through commercial prescription drug plans or Medicare Advantage (MA-PD) plans, and includes the following:

  • Prescription drugs
  • Biologicals
  • Insulin and insulin-related supplies defined as syringes, needles, gauze and swabs?
  • Certain vaccines

Plan formularies must include all, or substantially all, drugs in the following drug classes:

  • Antidepressants
  • Antipsychotics
  • Anticonvulsants
  • HIV/AIDS drugs
  • Immunosuppressants
  • Antineoplastics

Each drug plan has its own formulary that includes generic and brand-name drugs.

Plans may use a variety of utilization management tools such as: prior authorization, step therapy, and/or quantity limitations. These formularies can change; however, plans are required to notify their enrollees who use an affected drug, at least 60 days prior to the change.

Certain drugs/drug classes are excluded from Medicare Part D coverage. These are called the "federally excluded drug categories" and include: agents when used for anorexia, weight loss or weight gain; agents when used to promote fertility; agents when used for cosmetic purposes or hair growth; agents when used for the symptomatic relief of cough and colds; prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations; non-prescription drugs, barbiturates, and benzodiazepines.

Enrollment

In New York, enrollment in a Part D plan is a condition of Medicaid eligibility. This means that dual eligibles MUST be enrolled in a Medicare prescription drug plan (PDP) or a Medicare Advantage Prescription Drug Plan (MA-PD) or they may lose all of their New York State Medicaid benefits, including healthcare coverage. There are limited circumstances when a dual may not be required to join a Medicare drug plan (see information on retiree coverage).

The Centers for Medicare and Medicaid Services (CMS) randomly auto-assigns non Medicare Advantage dual eligible enrollees to one of 15 different benchmark PDPs if the recipient, or their legally authorized representative, does not choose their own plan. If the recipient has been auto assigned to a plan, CMS mails a letter, which is printed on yellow paper for ease of identification, to the recipient which identifies the plan to which they have been auto-assigned. The drug plan will then send an enrollment information package to the recipient, which will include plan identification cards or a letter indicating the beneficiary is covered under the plan.

If a dual eligible is enrolled in a Medicare Advantage plan, the recipient will receive their drug benefit through the plan if the plan has a drug benefit. MA-PDs must offer a benchmark plan. If the Medicare Advantage plan does not have a drug benefit, then the recipient can choose to join a MA-PD or choose traditional Medicare (A/B) and a Medicare PDP.

Both CMS and the Medicaid program recommend that dual eligibles sign up before the 10 th of the month to assure plan enrollment information is in place.

Recipients should be reminded to keep all their Medicare and Medicaid prescription drug information in one place. This information can be used to help the recipient, or others assisting the recipient, in understanding and using their drug benefit.

 

Enrollment Options for Dual Eligible Recipients

Medicaid recipients can change plans once a month, if necessary.

The "auto-assigned" PDP may or may not be the best match for an individual, based on a recipient's drug needs and the pharmacies which they currently use. Recipients may obtain assistance in finding a plan to better match their needs by calling 1-800-MEDICARE (1-800-633-4227), going to the CMS website, http://www.medicare.gov, or speaking with a Health Insurance Information, Counseling and Assistance Program (HIICAP) counselor at: 1-800-701-0501.

CMS has identified certain plans as "benchmark" plans. Dual eligible recipients should be encouraged to join these plans because they will not be responsible for any additional monthly premiums. If they choose to join other "non-benchmark" plans, they may be responsible for monthly premium payments.

Choosing a Plan

Only the recipient, or their legally authorized representative, can actually enroll the recipient in a plan. However, anyone can help the recipient choose a plan. The Department of Health has special authorized representative rules that apply to residents in nursing homes. The Office of Mental Retardation and Developmental Disabilities also has special rules that apply to clients receiving their services.

The Medicare Prescription Drug Plan Finder at http://www.medicare.gov/mpdpf is one way to find out what plans will meet a particular person's needs. You can also call 1-800-MEDICARE or the NYS HIICAP hotline (1-800-701-0501) for information and assistance.

Low Income Subsidy

Medicare's Low Income Subsidy (LIS) program provides "extra help" to low income Medicare beneficiaries by paying the Medicare Part D premiums, coinsurances and deductibles for eligible individuals. LIS beneficiaries have lower co-payments. Full dual eligible recipients automatically qualify for this extra help. Other beneficiaries may qualify under the following conditions:

  • They are enrolled in the Medicare savings program (extra help from New York State paying Medicare premiums and cost sharing).
  • They have income below 150% of the federal poverty level and resources below $10,000 for an individual and $20,000 for a couple.

A beneficiary must be enrolled in a plan for the LIS to apply. Seniors and disabled residents are encouraged to apply for LIS through the Social Security Administration. HIICAP staff are available to provide assistance in applying for LIS. HIICAP can be contacted by calling 1-800-701-0501.

How to Use the Medicare Drug Plan

Whether a recipient chooses their own plan or remains in the plan that was assigned by CMS, they will receive a Medicare prescription drug card in the mail. They must use this card at the pharmacy in the plan's network to receive prescription drugs. In some cases, Medicare prescription drug cards may not be available from the plans immediately after enrollment. Plans may issue letters to their enrollees that confirm the recipient's participation in their plan until the plan cards are issued. These letters should be taken by the recipient to the pharmacy when filling a prescription.

  • Beneficiaries are expected to fully maximize the benefits of the plan they are enrolled in by utilizing their plan's formularies. If a drug is not covered by the plan, or requires prior authorization, the plan's exception and appeal or prior authorization process should be used to obtain coverage for the non-formulary drug.
    • The prescriber may also change the prescription to a drug covered by the plan if medically appropriate.
    • Beneficiaries must obtain prescriptions at one of the plan's network pharmacies.

Co-payments and Cost Sharing

Dual eligible recipients are required to pay a co-payment (generally $1 for generics and $3 for brand and specialty drugs), even though a plan may have higher or tiered co-payments for their other members. Unlike Medicaid, co-payments must be paid by the recipient to obtain their drug. Medicare co-payments cannot be waived by the pharmacy unless done so on an individual, unadvertised basis. Dual eligibles should have no other out-of-pocket expenses, as long as they are enrolled in one of the 'benchmark' plans.

Dual eligibles residing in long term care institutions, including nursing homes, are not subject to co-payments once they have resided in the institution for one full calendar month.

If a dual eligible recipient is asked to pay more than the $1/$3 per drug at the pharmacy, the pharmacist can contact the recipient's Medicare Part D plan and request that the eligibility file be corrected to show that the recipient is a dual eligible recipient, and the co-payment be corrected to the appropriate amount. CMS has advised plans to make this correction while the recipient is at the pharmacy in order to avoid any delays in obtaining necessary medication.

Out-of-Pocket Maximum for Dual Eligible Recipients

Dual eligible individuals have the potential to reach the catastrophic coverage level each year. The CMS low-income subsidy (LIS) or "extra help" (which subsidizes the deductible, co-payments and other cost sharing) counts toward the true out-of-pocket (TrOOP) threshold. Once a dual reaches the out-of-pocket maximum for the year, they will not be responsible for co-payments for the remainder of the calendar year. The out-of-pocket maximum for 2006 is $3,600.

Long Term Care Facilities

Dual eligibles who reside in Long Term Care Facilities (LTCFs) such as nursing homes, ICF/MRs (Intermediate Care Facilities/Mentally Retarded), and residential psychiatric treatment centers will receive their prescription drug coverage from the plan and will not pay a premium, a deductible or co-payments when they have resided in the LTCF for at least one full calendar month. Dual eligible recipients that have met their residency requirements for long term care facility stays are not subject to co-payments. As such, pharmacy management tools that use a tiered co-payment do not apply.

Transition

  • Plans must take into account the unique needs of residents of LTCFs enrolled in a Part D plan. They must cover an "emergency supply" or "first fill" of non-formulary drugs for a long term care facility resident as part of their transition process to ensure that there is no gap in coverage while an exception or appeal is being processed.
  • The transition period is a time for action.
    • Confirm that the resident is in a plan that includes the long term care pharmacy that services the facility.
    • The patient's drug regimen should be reviewed and any necessary changes made to conform to the plan's formulary.
    • When medically necessary, a request for an exception for use of a non-formulary drug should be made to the recipient's plan by the prescriber. If a drug requires prior authorization, the prescriber should initiate the process.

Pharmacy Networks

  • Long term care institutions are encouraged to select one or more eligible network pharmacies who participate in the largest number of Part D plans. In-house or institutional pharmacies must be in the residents' plan networks to receive reimbursement from the plan. They must also be enrolled in Medicaid to receive payment for the Medicare excludable drugs and the limited Medicaid wrap-around benefit.

OMH/OMRDD Residential Facilities

LTCFs serving the Office of Mental Health's (OMH), or Office of Mental Retardation/Development Disabilities' (OMRDD) dual eligible population should contact the following offices for more detailed information about the Medicare prescription drug program and how it affects their Medicaid population including information on authorized representatives:

OMH (518) 473-6655 or (518) 473-3598
OMRDD (518) 473-9697

DOH Nursing Homes

The following information pertains to DOH regulated nursing homes only.

Highlights of DOH Guidance on Authorized Representatives

Residents who have legal capacity to act on their own behalf to make decisions regarding Part D:

  • Should exercise their right to do so.
  • May legally authorize other individuals to act on their behalf.
  • May authorize the provider's administrator or administrator's designee.

Residents who lack legal capacity to act on their own behalf and

  • Already have a legally authorized representative
    • The legally authorized representative can make decisions regarding Part D on their behalf.
      or
  • Do not have an existing legally authorized representative
    • Family members and other parties who have an interest in the well-being of the resident can legally authorize a "designated representative," including themselves.

When no relative or community member has an interest in the well-being of the resident,

  • The DOH would authorize the facility to establish the administrator or administrator's designee to act as "designated representative" in these exceptional instances.

Questions regarding authorized representatives should be submitted to nhinfo@health.state.ny.us with a subject heading of "Authorized Representative."

Medicare Excludable Drugs

  • Medicaid will continue to pay for barbiturates, benzodiazepines and select prescription vitamins on a fee-for-service basis in the LTCF setting. These drugs can be billed directly to Medicaid.
  • Over-the-counter (OTC) drugs remain in the nursing home rate and cannot be billed separately to Medicaid.

LTCF Enrollment and Eligibility Considerations

  • For a resident who is admitted to a nursing home with a Medicare prescription drug plan and is Medicaid pending, the Medicare prescription drug plan will pay the cost of the drugs and the resident is responsible for meeting their cost sharing responsibilities.

    If the resident is paying their own Medicare plan premium and other plan cost sharing, they should apply for "extra help" (the low income subsidy) while Medicaid is pending. This will reduce their out-of-pocket expenses. Once they become Medicaid eligible and have resided in the nursing home for one full calendar month, the resident will not have cost sharing. The resident stay should be billed retroactively to the Medicaid eligibility date using the rate that excludes the drug component.
  • When a resident is admitted to a nursing home without Medicare Part D and is Medicaid pending, the facility should assist the resident in choosing and enrolling in a Medicare plan and assist them with applying for the LIS while their Medicaid is pending. The Medicaid nursing home rate that includes the drug component cannot be used once the recipient is enrolled in a Medicare Part D plan. Once the resident is enrolled in Medicare Part D, the nursing home rate without the drug component is to be used.

Medicare Part D and Retiree Benefits, Spenddown, and EPIC
Return to Table of Contents

Retiree Drug Coverage

Dual eligibles who have other health insurance provided by their former employer or union retiree drug plan sponsor may have been informed that they, or their dependent, will only continue to receive their retiree drug benefits, and in some cases their retiree medical benefits, if they do not enroll in a Medicare drug plan.

In New York, enrollment in Medicare Part D is a condition of Medicaid eligibility. Refusal to participate in Medicare Part D may result in the loss of all Medicaid benefits. However, if an individual can prove "good cause" for not participating in Medicare Part D, Medicaid benefits may be continued. A finding of good cause may only be found to exist in situations where it is determined that the Medicaid applicant/recipient or his/her dependents will lose cost effective health insurance benefits if the Medicaid applicant/recipient enrolls in Medicare Part D. A determination of cost effectiveness is determined solely by the local department of social services. Proof of such loss in benefits must be presented to the local Medicaid office.

Spenddown

Certain individuals who have used their prescription costs to help meet their spenddown may find that Medicare covers their drug spending and they no longer "spend down" as quickly to become Medicaid eligible. However, with Medicare paying for prescription drugs, recipients will have more available income. Any out-of-pocket costs paid or incurred for items such as the Part D premium, coinsurance, deductible or co-payments may be used to meet a spenddown. Medical expenses, other than prescription drug costs, may continue to be used to meet a spenddown.

EPIC and Spenddown

EPIC enrollees who must meet a spenddown before receiving Medicaid benefits can keep their EPIC coverage, and others not currently enrolled can continue to join EPIC. The following questions and answers are provided to clarify how seniors should use all of their prescription drug benefits.

  1. Will seniors on a Medicaid spenddown and in EPIC be automatically enrolled into a Medicare Part D drug plan?

    Yes. Once a senior meets their Medicaid spenddown and begins receiving full Medicaid benefits, they will be deemed eligible for the low-income subsidy and automatically be enrolled by CMS into a Medicare Part D plan for the remainder of the calendar year. Once enrolled in Part D with the full subsidy, their EPIC enrollment fee will be waived.

  2. After being automatically enrolled in a Medicare Part D drug plan, can seniors continue to use their EPIC coverage?

    Yes. The senior's Medicare Part D drug plan is always primary and their EPIC coverage will be secondary. This means that their pharmacist must first submit their prescription drug claims to the Part D plan, and then submit any drug costs not covered by the Part D plan to EPIC for coverage. EPIC will cover most drugs not covered by the Part D plan, in which case the senior would pay the EPIC co-payment of $3-$20. EPIC can also be used to cover any Part D co-payments over $3 (for example, the $5 Part D co-payment for brand name drugs could be reduced to $3 with EPIC).

  3. Prior to meeting their spenddown, can seniors choose to use EPIC as a primary plan rather than their Medicare Part D coverage?

    No. The Medicare Part D plan is primary and must be used first, before EPIC. Any drug costs not covered by Medicare (i.e., drugs not covered, co-payments) can be submitted to EPIC for coverage.

  4. For seniors with a Medicaid spenddown, along with Medicare Part D coverage and EPIC, what drug costs will be applied to their Medicaid spenddown?

    When the drug is covered by their Medicare drug plan, the $1 (or $2) co-payment for generic drugs and a $3 (or $5) co-payment for a brand name drug is applied towards their Medicaid spenddown. When EPIC is used to pay for drugs not covered by the senior's Medicare Part D plan, both the EPIC paid amount and the EPIC co-payment ($3-$20) paid by the senior can be applied towards their Medicaid spenddown.

  5. After seniors meet their spenddown, do they use EPIC or Medicaid for the drugs that are not covered by their Medicare drug plan?

    They can use either Medicaid or EPIC (but not both) for drugs that are not covered by the Medicare Part D drug plan. However, when using Medicaid, if the claim is approved, the senior will pay a much lower co-payment, than by using their EPIC coverage, which requires a co-payment of $3 to $20.

For more information on Medicare Part D and the EPIC Program, contact EPIC at 1-800-332-3742.


Guidance for Prescribers and Pharmacists on Medicare
Part B vs. Part D Drugs
Return to Table of Contents

Drug Coverage under Medicare Part B

  • Rules for Medicare Part B coverage and billing have not changed
  • Part B should be billed first for covered Part B drugs
  • Medicaid's cost sharing role for Part B covered drugs has not changed
  • If Part B denies the drug claim, the Medicare Part D plan can be billed

Policy and coverage under Part B vs. Part D can be very confusing. CMS is recommending that prescribers include additional information on prescriptions that may help Part D plans and pharmacists differentiate between those drugs filled by pharmacies that may qualify as Part D drugs or as Part B drugs.

Please consider this guidance when prescribing or dispensing drugs to your Medicare patient.

Pills

Prescribers: Please include the diagnosis or location of administration on the prescription to facilitate coverage determination.

For example, a prescription for methotrexate for rheumatoid arthritis should have the diagnosis specified and the designation "Part D" added to the prescription.

Part B may cover drugs when administered in the physician's office but not a nursing home. It would be very helpful if the prescriber could specify on the prescription where the drug was administered, for example, in the nursing home.

Pharmacists: Plans may rely on the pharmacist's report of appropriate information to make the coverage determination under Part D, which may include the information provided by the prescriber.

To simplify access to the Part D drug benefit in the outpatient setting, the following guidance can be used to help differentiate drugs which may qualify as Part B drugs from those which may qualify as Part D drugs.

At this time, Part B covers the oral anti-cancer, oral anti-emetic, and immunosuppressive drugs listed below under certain circumstances. This does not represent an exhaustive list of Part B covered drugs. It is possible for the list of drugs covered by Part B to change over time.

I. Drugs administered through a Part B covered item of durable medical equipment (DME) such as a nebulizer or pump.

  • Medicare Part B only covers drugs when used in conjunction with durable medical equipment in the patient's home. For those long-term care facilities that do not qualify as a patient's home, it is recommended to include in the written order both the diagnosis and indication for the drug, and a statement of status, such as "Nursing Home Part D." (See the following section on Medicare Part B versus Part D coverage: Special Considerations -Long Term Care and Home Infusion for more information regarding the definition of a home.)

II. Certain Infusion and Injectable Drugs

  • In addition, Medicare Part B covers injectable and infusible drugs that are not usually self-administered and that are furnished coincident to a physician's service. If a long-term care facility (other than a physician) administers these drugs to a non Part A patient, the drug is not covered under Part B because it is not administered coincident to a physician's service. In this situation, we recommend including a statement of status such as "Administered by facility, Nursing Home Part D."

III. Immunosuppressive Drugs for Transplants Covered by Medicare B

  • 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
  • Oral Azathioprine
  • Parenteral Azathioprine
  • Prednisolone-Oral
  • Prednisone-Oral
  • Sirolimus-Oral
  • Tacrolimus-Oral
  • Tacrolimus-Parenteral

IV. Oral Anti-cancer Drugs Covered by Part B

  • Busulfan Capecitabine
  • Cyclophosphamide
  • Etoposide
  • Melphalan
  • Methotrexate
  • Temozolomide

V. Oral anti-emetics Prescribed for use within 48-hours of Chemotherapy are covered by Part B. Drugs below with the 24 hour qualifier (dolasetron mesylate and granisetron hydrochloride) are only considered Part B if used within 24 hours of chemotherapy.

  • 3 Oral Drug Combination of: (1) Aprepitant; (2) A 5-HT3 Antagonist (Q0166, Q0179, Q0180); and (3) Dexamethasone
  • Chlorpromazine Hydrochloride
  • Diphenhydramine Hydrochloride
  • Dolasetron Mesylate (Q0180) (Within 24 Hours)
  • Dronabinol
  • Granisetron Hydrochloride (Q0166) (Within 24 Hours)
  • Hydroxyzine Pamoate
  • Ondansetron Hydrochloride (Q0179)
  • Perphenazine
  • Prochlorperazine Maleate
  • Promethazine Hydrochloride
  • Thiethylperazine Maleate
  • Trimethobenzamide Hydrochloride

For these drugs, we recommend including in the written prescription, the diagnosis, the indication, and the statement of status as "Part B" (for above indications) or "Part D" (for all other indications). As an example, methotrexate for rheumatoid arthritis should have the diagnosis specified, and the designation "Part D" added to the prescription.

While this guidance does not guarantee payment or coverage, following the process may help pharmacists respond more readily to additional information to support Part D or Part B coverage and facilitate appropriate processing by the plan. This information does not supersede any existing guidance concerning documentation for Part B prescriptions.


Medicare Part B versus Part D coverage:
Special Considerations - Long Term Care and Home Infusion
Return to Table of Contents

Long Term Care Settings

Part D does not alter Part A or B coverage. Drugs and items that are covered by Medicare Part B will continue to be reimbursed under Part B. However, drugs that are not covered by Part B for LTC residents may now be covered under Part D. In particular, the Medicare Part B durable medical equipment (DME) benefit covers a limited number of drugs that require the use of an infusion pump "in the home" and covers inhalation drugs that require the use of a nebulizer "in the home."

Building

Certain LTC facilities are not considered a "home" for the purpose of the DME benefit, and thus when DME drugs are administered in these facilities, they would have coverage under Part D.

Facilities that are not considered a home include:

  • a skilled nursing facility (SNF),
  • a distinct part SNF,
  • 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 (i.e., neither Medicare nor Medicaid) that provides primarily skilled care, or an institution which has a distinct part SNF and which also primarily furnishes skilled care.

Enrolled beneficiaries in these facilities who require DME drugs would have coverage under Part D to the extent that they are not covered under Part A.

In addition to DME drugs, Medicare Part B also covers a number of infusible or injectable drugs that are administered incident to a physician service. If a LTC facility, rather than a physician, administers such a drug to a beneficiary (whose stay is not covered by Part A), the drug would not be covered by Part B, and the beneficiary would have coverage for the drug under Part D subject to the Part D plan's rules or transition policy for first fills.

Home Infusion Drugs

With the transfer of responsibility for outpatient drugs for dual eligibles from Medicaid programs to Medicare Part D prescription drug plans, Medicaid programs no longer must pay for home infusion drugs. Because of the separate coverage responsibilities for components of home infusion services, providers may be required to bill both the Medicare drug plan and NYS Medicaid in order to receive payment.

Needle

Medicare Part D requires coverage of home infusion drugs that are not currently covered under Parts A and B of Medicare. Although the Medicare Part D benefit does not cover equipment, supplies and professional services associated with home infusion therapy, it does cover the ingredient costs and dispensing fees associated with infused covered Part D drugs.

In addition, CMS notes that the Part D plan's contracted pharmacy is expected to deliver home infused drugs in a form that can be administered in a clinically appropriate fashion. Home infusion networks must have contracted pharmacies capable of providing infusible Part D drugs for both short-term acute care (e.g., IV antibiotics) and long-term chronic care (e.g., alpha 1 protease inhibitor). However, the same network pharmacy does not necessarily need to be capable of providing the full range of home infusion Part D drugs to ensure that enrollees have adequate access to medically necessary home infusion therapies.

Generally, facility discharge planners, in collaboration with a patient's physician, are responsible for ensuring that the components needed to safely administer a drug at home are present upon a patient's discharge. However, the Part D plan's in-network contracted pharmacy vendor-particularly a vendor that does not supply the necessary ancillary services (which are not Medicare Part D benefits)-must seek assurances that another entity, such as a home health agency, can arrange for the provision of these services. In other words, Part D plans must require their contracted network pharmacies that deliver home infusion drugs to ensure that the professional services and ancillary supplies are in place before dispensing home infusion drugs.

Supplies and service components associated with home infusion that are not covered under Medicare B may be billed to Medicaid. NYS Medicaid does not provide a bundled payment to cover drug, supplies and services associated with home infusion treatments.

CMS has provided a chart that provides a quick reference guide for the most frequent Medicare Part B drug and Part D drug coverage determination scenarios. It does not address all possible situations. For a more extensive discussion, please refer to "Medicare Part B vs. Part D Coverage Issues" at:

http://www.cms.hhs.gov/PrescriptionDrugCovGenIn/Downloads/PartBandPartDdoc_07.27.05.pdf.

A copy of this chart is also found in the Appendix.



Important Contact Information
Medicare Part D

Contact Information for Prescribers
Return to Table of Contents

For questions regarding recipient plan coverage or to file a complaint:

Contact Information for Pharmacists

For questions regarding recipient plan coverage or to file a complaint:

Contact Information for Recipients

For questions regarding recipient plan coverage or to file a complaint:

  • The recipient's plan
  • Medicare
  • Health Insurance Information, Counseling and Assistance Program (HIICAP) 1-800-701-0501

Medicare Prescription Drug Benchmark Plans
Return to Table of Contents

Medicare Prescription Drug Benchmark Plans
American Progressive Insurance Co.
Prescription Pathway Bronze Plan Reg 3
http://www.rxpathway.com/
Recipient customer service 800-766-3233
Pharmacists & prescribers 800-698-8394
Exceptions 888-862-2699 ext. 6101
Pacificare Insurance Company
Pacificare Saver & Pacificare Select Plan
https://www.prescriptionsolutions.com/
Recipients, pharmacists & prescribers
can call 800-797-9794
Exceptions 800-711-4555
Excellus Health Plan, Inc.
Simply Prescriptions
https://www.excellusbcbs.com/
Recipient customer service 800-514-6930
Pharmacists & prescribers 800-724-5033
Exceptions 800-724-5033
Silverscript Insurance Company
Silverscript
https://www.silverscript.com/
Recipient customer service 866-235-5660
Pharmacists & prescribers 800-364-6331
Exceptions 866-884-9479
First Health
First Health Premier
https://www.firsthealthpremier.com/
Recipient customer service 888-975-8989
Pharmacists & prescribers 800-421-2342
Unicare (Anthem)
Medicare Rx Rewards
https://www.unicare.com
Recipient customer service 800-928-6201
Pharmacists & prescribers 800-662-0210
Exceptions 800-662-0210
Group Health Incorporated (GHI)
GHI Medicare Prescription Drug Plan
https://www.ghi.com/
Recipient customer service 866-557-7300
Pharmacists 800-824-0898
Exceptions 800-417-8164
United Healthcare Insurance Co of NY
United HealthRx
https://www.unitedhealthrx.net
Recipient customer service 866-255-4515
Pharmacists & prescribers 888-492-2949
Exceptions 888-492-2971
Health Net Insurance of NY
Health Net Orange
https://www.healthnet.com
Recipient customer service 800-806-8811
Prescribers 800-867-6564
Pharmacists help desk 800-693-8951
Exceptions 800-533-0921
United Healthcare Insurance Co of NY
AARP MedicareRx Plan
https://www.AARPMedicareRx.com/
Recipient customer service 866-255-4515
Pharmacists & prescribers 888-492-2952
Exceptions 888-492-2971
Humana Insurance Company of NY
Humana PDP Standard
https://www.humanamedicare.com
Recipient customer service 800-281-6918
Pharmacists & prescribers 800-448-6262
Pharmacy help desk 800-865-8715 or
800-555-2546
Exceptions 800-555-2546
United Healthcare Insurance Co of NY
United Medicare MedAdvance
https://www.unitedmedicareadvance.com/
Recipient customer service 866-255-4515
Pharmacists & prescribers 888-747-5736
Exceptions 888-492-2971
  Wellcare Health Plans
Wellcare Signature
https://www.wellcare.com/medicare/
Customer service for recipients,
Pharmacists & prescribers 888-550-5252
or 800-278-5155
Exceptions 866-800-6111

Approved OMB #0938-0975

Medicare Prescription Drug Coverage And Your Rights
Return to Table of Contents

You have the right to get a written explanation from your Medicare drug plan if:

  • Your doctor or pharmacist tells you that your Medicare drug plan will not cover a prescription drug in the amount or form prescribed by your doctor
  • You are asked to pay a different cost-sharing amount that you think you are required to pay for a prescription drug.

The Medicare drug plan's written explanation will give you the specific reasons why the prescription drug is not covered and will explain how to request an appeal if you disagree with the drug plan's decision.

You also have the right to ask your Medicare drug plan for an exception if:

  • You believe you need a drug that is not on your drug plan's list of covered drugs. The list of covered drugs is called a "formulary"; or
  • You believe you should get a drug you need at a lower cost-sharing amount

What you need to do:

  • Contact your Medicare drug plan to ask for a written explanation about why a prescription is not covered or to ask for an exception if you believe you need a drug at a lower cost-sharing amount.
  • Refer to the benefits booklet you received from your Medicare drug plan or call 1-800-MEDICARE to find out how to contact your drug plan.
  • When you contact your Medicare drug plan, be ready to tell them:
    1. The prescription drug(s) that you believe you need
    2. The name of the pharmacy or physician who told you that the prescription drug(s) is not covered.
    3. The date you were told that the prescription drug(s) is not covered.

According to the Paperwork reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0975. The time required to distribute this information collection once it has been completed is one minute per response, including the time to select the preprinted form, and hand it to the enrollee. If you have any comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850

No. CMS-10147


CHARGING OF FEES FOR REPRESENTING BENEFICIARIES BEFORE THE SECRETARY OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES

An attorney, or other representative for a beneficiary, who wishes to charge a fee for services rendered in connection with an appeal before the Department of Health and Human Services (DHHS) at the Administrative Law Judge (ALJ) or Medicare Appeals Council (MAC) level is required by law to obtain approval of the fee in accordance with 42 CFR§405.910(f). A claim that has been remanded by a court to the Secretary for further administrative proceedings is considered to be before the Secretary after the remand by the court

The form, "Petition to Obtain Representative Fee" elicits the information required for a fee petition. It should be completed by the representative and filed with DHHS. Where a representative has rendered services in a claim before the Secretary of DHHS be specified. If any fee is to be charged for such services, a petition for approval of that amount must be submitted.

An approval of a fee is not required where the applicant is a provider or supplier or where the fee is for services (1) rendered in an official capacity such as that of legal guardian, committee, or similar court-appointed office and the court has approved the fee in question; (2) in representing the beneficiary before the federal district court of above, or (3) in representing the beneficiary in appeals below the ALJ level. If the representative wishes to waive a fee, he or she may do so. Section III on the front of this form can be used for that purpose. In some instances, as indicated on the form, the fee must be waived for representation.

AUTHORIZATION OF FEE

The requirement for approval of fees ensures that representative will receive fair value for the services performed before DHHS on behalf of a claimant while at the same time giving a measure of security to the beneficiaries. In approving a requested fee, the ALJ or MAC considers the nature and type of services performed, the complexity of the case, the level of skill and competence required in rendition of the services, the amount of time spent on the case, the results achieved, the level of administrative review to which the representative carried the appeal and the amount of the fee requested by the representative.

CONFLICT OF INTEREST

Sections 203, 205, and 207 of Title XVIII 0f the United States Code make it a criminal offense for certain officers, employees and former officers and employees of the United States to render certain services in matters affecting the Government or to aid or assist in the prosecution of claims against the United States. Individuals with a conflict of interest are excluded from being representatives of beneficiaries before DHHS.

________________________________

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0950. The time required to prepare and distribute this collection is 15 minutes per notice, including the time to select the preprinted form, complete it and deliver it to the beneficiary. If you have comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, PRA Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 2144-1850.

Form CMG-1696 (07/05) EF (07/05)



Medicare Parts B/D Coverage Flashpoints

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: http://www.cms.hhs.gov/PrescriptionDrugCovGenin/downloads/PartBandPartDdoc_07.27.05.pdf

Part B Coverage CategoriesPart B Coverage DescriptionRetail and Home Infusion Pharmacy Setting B/D CoverageLTC Pharmacy Setting B/D CoverageComments
Durable Medical Equipment (DME) Supply Drugs
NOTE: Only available for beneficiaries residing in their "home"1
Drugs that require administration via covered DME (e.g. inhalation drugs. IV drugs "requiring" 2 a pump for infusion, insulin via infusion pump)3 Part BPart D
Because most LTC facilities are not considered a beneficiary's "home"4
Blood Glucose Testing Strips and Lancets covered under Part B DME benefit are never available under Part D because they are not Part D drugs.
Drugs furnished "incident to" a physician service Injectable/intravenous drugs
1) administered "incident to" a physician service and 2) considered by Part B carrier as not usually self administered".
Part D
Because by definition a pharmacy cannot provide a drug "incident to" a physician's service (Only a physician office would bill Part B for "incident to" drugs).
Part D
Because by definition a pharmacy cannot provide a drug "incident to" a physician's service (Only a physician office would bill Part B for "incident to" drugs).
Part D plans should not implement pharmacy edits to determine B vs D coverage for injectable/IV drugs only covered under Part B when furnished "incident to" a physician service.

________________________________________
1In 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 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 (i.e. neither Medicare not Medicaid) that provides primarily skilled care and
  • An institution which has a distinct part SNF and which also primarily furnishes skilled care.

2The DMERCs determines whether or not an IV drug requires a pump for infusion.
3The DMERCs do a medically necessity determination with regard to whether a nebulizer or infusion pump is medically necessary for a specific drug/condition.
4If a facility does not meet the criteria in footnote 1, it would be considered a home, and Part B could cover the drugs.


Medicare Parts B/D Coverage Flashpoints

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: http://www.cms.hhs.gov/PrescriptionDrugCovGenin/downloads/PartBandPartDdoc_07.27.05.pdf

Part B Coverage CategoriesPart B Coverage DescriptionRetail and Home Infusion Pharmacy Setting B/D CoverageLTC Pharmacy Setting B/D CoverageComments
Immunosuppressant Drugs Drugs used in immunosuppressive therapy for beneficiaries that received transplant from Medicare approved facility and were entitled to Medicare Part A at time of transplant (i.e. "Medicare Covered Transplant"). B or D:
Part B
for Medicare Covered Transplant

Part D for all other situations
B or D:
Part B
for Medicare Covered Transplant

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

Part D for all other indications
B or D:
Part B
for cancer treatment

Part D for all other indications
Participating Part B pharmacies must bill the DMERC in their region when these drugs are covered under Part B.
Oral Anti-emetic Drugs Oral anti-emetic drugs used as full therapeutic replacement for IV antiemetic drugs within 48 hours of chemo B or D:
Part B
within 48 hrs of chemo

Part D for all other situations
B or D:
Part B
within 48 hrs of chemo

Part D for all other situations
Participating Part B pharmacies must bill the DMERC in their region when these drugs are covered under Part B.

Medicare Parts B/D Coverage Flashpoints

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: http://www.cms.hhs.gov/PrescriptionDrugCovGenin/downloads/PartBandPartDdoc_07.27.05.pdf

Part B Coverage CategoriesPart B Coverage DescriptionRetail and Home Infusion Pharmacy Setting B/D CoverageLTC Pharmacy Setting B/D CoverageComments
Erythropoietin (EPO)Treatment of anemia for person with chronic renal failure who are undergoing dialysis B or D:
Part B
for treatment of anemia for beneficiaries undergoing dialysis

Part D for all other situations
B or D:
Part B
for treatment of anemia for beneficiaries undergoing dialysis

Part D for all other situations
EPO may be covered under Part B "incident to" physician's service for other indications but a pharmacy would not be billing for "incident to" drugs
Prophylatic Vaccines Influenza: Pneumococcal; and Hepatitis B (for intermediate to high risk beneficiaries). B or D:
Part B
for Influenza, Pneumococcal, & Hepatitis B (for intermediate to high risk)

Part D for all others
B or D:
Part B
for influenza, pneumococcal & Hepatitis B (for high risk)

Part D for all others
Vaccines given directly related to the treatment of an injury or direct exposure to a disease or condition are always covered under Part B
Parenteral Nutrition Prosthetic benefit for individuals with "permanent" dysfunction of the digestive tract. If medical record, including the judgment or the attending physician, indicates that the impairment will be long and indefinite duration, the test of permanence is met. B or D:
Part B
if "permanent" dysfunction of digestive tract

Part D for all other situations
B or D:
Part B
if "permanent" dysfunction of digestive tract

Part D for all other situations
Part D does not pay for the equipment/supplies and professional services associated with the provision of parenteral nutrition or other Part D covered infusion therapy.

The Medicaid Update: Your Window Into The Medicaid Program

The State Department of Health welcomes your comments or suggestions regarding the Medicaid Update.

Please send suggestions to the editor, Timothy Perry-Coon:

NYS Department of Health
Office of Medicaid Management
Bureau of Program Guidance
99 Washington Ave., Suite 720
Albany, NY 12210
(e-mail MedicaidUpdate@health.state.ny.us)

The Medicaid Update, along with past issues of the Medicaid Update, can be accessed online at the New York State Department of Health web site:http://www.health_care/medicaid/program/update/main.htm

Please Note

Some documents on this page are saved in the Portable Document Format (PDF). If it's not already on your computer, you'll need to download the latest free version of Adobe Reader.