The term “drug” means “drug or biological.” Drugs that are covered under Medicare Part B are governed by the Original Medicare regulations and local coverage decisions. For more coverage details, see the Medicare Benefits Policy Manual Publication 100-02, Chapter 15, Section 50 “Drugs and Biologicals” and the Medicare Claims Processing Manual, Publication 100-04, Chapter 17, and sections of the Manual referenced therein.
The following broad categories of drugs may be covered under Medicare Part B, subject to coverage requirements and regulatory and statutory limitations. Note that these examples are illustrative and do not comprise a comprehensive list.
• Injectable drugs that have been determined by Medicare Administrative Contractors (MACs) to be “not usually self-administered” and that are administered incident to physician services. For further information, see the Medicare Policy Benefits Manual Publication 100-02, Chapter 15, Section 50.2 and 50.3.
• Drugs that the MA enrollee takes through durable medical equipment (such as nebulizers) that were authorized by the enrollee’s MA plan.
• Drugs covered under the Act, include but are not limited to:
- Certain vaccines including pneumococcal, hepatitis B (high or intermediate risk only) influenza, and vaccines directly related to the treatment of an injury or direct exposure to a disease or condition. For further details, see section 126.96.36.199 of Chapter 15 of the Medicare Benefit Policy Manual: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf ;
- Certain oral anti-cancer drugs and anti-nausea drugs;
- Hemophilia clotting factors;
- Immunosuppressive drugs;
- Some antigens;
- Intravenous immune globulin administered in the home for the treatment of primary immune deficiency;
- Injectable drugs used for the treatment of osteoporosis in limited situations; and
- Certain drugs, including erythropoietin, administered during the treatment of end stage renal disease.
If an MA enrollee wishes to receive a “not usually self-administered” drug in a physician’s office, then the MAO must cover the drug and the service of administering the drug. MAOs may not determine whether it was reasonable and necessary for the patient to choose to have his or her drug administered incident to physician services. MAOs can continue to make determinations concerning the appropriateness of a drug to treat a patient’s condition and the appropriateness of the intravenous or injection form, as opposed to the oral form of the drug.
Injectable drugs that the applicable MAC has determined are not usually self-administered, but that members purchase at a pharmacy and administer at home may only be offered by MAOs as a Part D benefit. However, MA enrollees always have the option of receiving the Medicare-covered benefit, i.e., administration of the covered drug, in a physician’s office from the physician’s stock of drugs.
Some drugs are covered under either Part B or Part D depending on the circumstances. For clarification on coverage under Part B versus Part D, see Appendix C of Chapter 6 of the Part D Prescription Drug Benefit Manual located at: http://www.cms.hhs.gov/PrescriptionDrugCovContra/downloads/R2PDBv2.pdf. It is critical to understand when a drug is covered under Part B or Part D in order to ensure that Part C and Part D bids properly reflect appropriate coverage under either Part B or Part D.