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Medicare Parts B/d Coverage Issues

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

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 (e.g. 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.
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
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 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.

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

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 (i.e. “Medicare
Covered Transplant”).
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.
situations



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

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).
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.


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