Medicare Drug Coverage Under Part A, Part B and Part D

1. Medicare Drug CoverageUnder Part A, Part B and Part D Module 8

2. Session Topics • Overview • Drug coverage under Medicare Part A • Drug coverage under Medicare Part B • Medicare Prescription Drug Coverage—Part D • Medicare Parts A/B/D Coordination • Information Sources Medicare Drug Coverage Under Part A, Part B and Part D

3. Medicare Parts A, B, and D • Determining if coverage is under Part A, B, or D • What is the health care setting • e.g., home, hospital, surgery center or institution • What is the medical indication • e.g., to treat cancer • Are there special coverage requirements • e.g., those for immunosuppressive drugs Medicare Drug Coverage Under Part A, Part B and Part D

4. Parts A and B Coverage in Original Medicare • Parts A and B • Cover some drugs in certain situations • Generally don’t cover outpatient drugs • Most are now covered under Part D • For Medicare coverage under Parts A, B, or D • Drugs must be medically necessary Medicare Drug Coverage Under Part A, Part B and Part D

5. Part A Drug Coverage • Generally covers all drugs during a covered stay • Hospital or skilled nursing facility (SNF) • Receiving drugs as part of treatment • Part B can pay for some Part B covered drugs in hospitals and SNFs • If you don’t have Part A or your coverage has run out • The stay is not covered by Part A • Part D may pay for formulary drugs • If not admitted • May have to pay and submit for reimbursement Medicare Drug Coverage Under Part A, Part B and Part D

6. Drug Coverage for Hospice Care • When receiving Medicare-covered hospice care • Part A • Covers drugs for symptom control or pain relief • Will not coverdrugs to cure the terminal illness • Part D • May pay for drugs to treat conditions unrelated to the terminal illness Medicare Drug Coverage Under Part A, Part B and Part D

7. 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 • Administered through Part B-covered Durable Medical Equipment (DME) • Some other types of drugs Medicare Drug Coverage Under Part A, Part B and Part D

8. Part B Drug Coverage DME Drugs • Drugs administered through Part B-covered DME • Such as nebulizers and pumps • Only when used with DME in patient’s home • Supplier must be DME provider • In some areas must be contract provider • Ask if supplier is accredited • Drug must be medically necessary • According to guidelines Medicare Drug Coverage Under Part A, Part B and Part D

9. Part B Drug Coverage – Certain Oral Drugs • Oral drugs with special coverage requirements • Anti-cancer drugs • Anti-emetic drugs • Immunosuppressive drugs, under certain circumstances Medicare Drug Coverage Under Part A, Part B and Part D

10. Oral Anticancer Drugs* • Busulfan • Capecitabine • Cyclophosphamide • Etoposide • Melphalan • Methotrexate • Temozolomide *List is subject to change Medicare Drug Coverage Under Part A, Part B and Part D

11. 3 oral drug combination of Aprepitant A 5-HT3 Antagonist 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 Trimethobenzamide Hydrochloride Oral Anti-Emetics Prescribed for Use Within 48 Hours of Chemotherapy* *List is subject to change Medicare Drug Coverage Under Part A, Part B and Part D

12. 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 Immunosuppressive Drugs* *List is subject to change Medicare Drug Coverage Under Part A, Part B and Part D

13. Medicare Drug Coverage Under Part A, Part B and Part D

14. Hospital Outpatient Settings • Part B doesn’t cover “self-administered drugs” • Unless required for the hospital outpatient services • Part D may cover these drugs • If requirements under Part A or Part B are not met • You may need to pay up front • Submit the claim to Part D plan for refund • Check with the hospital to see if it participates in Part D Medicare Drug Coverage Under Part A, Part B and Part D

15. Part D-covered Drugs • Prescription brand-name and generic drugs • Approved by FDA • Used and sold in U.S. • Used for medically-accepted indications • Include drugs, biologicals, and insulin • Supplies associated with injection or inhalation Medicare Drug Coverage Under Part A, Part B and Part D

16. Required Coverage Health Reform Section 3307 • “All” drugs in 6 categories • Cancer medications • HIV/AIDS treatments • Antidepressants • Antipsychotic medications • Anticonvulsive treatments for epilepsy and other conditions • Immunosuppressants Medicare Drug Coverage Under Part A, Part B and Part D

17. Vaccines • All Part D drug plans must cover • All commercially available vaccines (e.g., shingles vaccine) • Except those covered under Part B (e.g., flu shot) • Contact drug plan for more information Medicare Drug Coverage Under Part A, Part B and Part D

18. Drugs Not Covered by Part D • Excluded by law from Medicare coverage • Anorexia, weight loss or weight gain drugs • Barbiturates and benzodiazepines* • Erectile dysfunction drugs when used for the treatment of sexual or erectile dysfunction • Fertility drugs • Drugs for cosmetic or lifestyle purposes (e.g., hair growth) • Drugs for symptomatic relief of coughs and colds • Prescription vitamin and mineral products (except prenatal vitamins and fluoride preparations) • Non-prescription drugs *To be covered in 2013 Medicare Drug Coverage Under Part A, Part B and Part D

19. Your Rights • Plan doesn’t cover a drug or • Drug cost higher than you think you should pay • Follow plan’s process to request coverage determination • Ask for an exception (a type of coverage determination) • You can appeal if request is denied • Pharmacist will explain how to contact your drug plan Medicare Drug Coverage Under Part A, Part B and Part D

20. Part D Coverage Determinations • Part D plan coverage determination • May rely on information from physicians • Should not replace plan’s process • Pharmacists help in determining Part D status • Explain prior authorization requirements • Provide more information to plan Medicare Drug Coverage Under Part A, Part B and Part D

21. Part D Exception Requests • Two types of exceptions • Tiers • e.g., getting Tier 2 drug at Tier 1 cost • Formulary • Drug not on plan’s formulary or • Access requirements • Requests can be made only by you, your appointed representative, or the prescriber • Requires supporting statement from physician Medicare Drug Coverage Under Part A, Part B and Part D

22. Levels of Appeal • Redetermination with the Part D plan (sponsor) • Reconsideration with the independent review entity • Hearing with an administrative law judge • Review by the Medicare Appeals Council • Review by a federal district court Medicare Drug Coverage Under Part A, Part B and Part D

23. Part D Coordination of Benefits Employer Group Health Plan (EGHP) Situations Medicare Drug Coverage Under Part A, Part B and Part D

24. Part D Coordination of Benefits Non-Employer Group Health Plan Situations Medicare Drug Coverage Under Part A, Part B and Part D

25. Exercise A. Most outpatient drugs are covered under Medicare Part A. • True • False Medicare Drug Coverage Under Part A, Part B and Part D

26. Exercise B. Medicare Part A payments made to hospitals and Skilled Nursing Facilities generally cover all drugs provided during a stay. • True • False Medicare Drug Coverage Under Part A, Part B and Part D

27. For More Information… • Contact your Medicare drug plan • Read the Medicare & You handbook - CMS Pub. # 10050 • Visit “Compare Medicare Prescription Drug Plans” at www.medicare.gov • Read Your Guide to Medicare Prescription Drug Coverage – CMS Pub. # 11109 • Call your State Health Insurance Assistance Program • Call 1-800-MEDICARE (TTY users should call 1-877-486-2048) • For forms, e.g., a Request for Coverage Determination, visit http://www.cms.hhs.gov/MedPrescriptDrugApplGriev/13_Forms.asp Medicare Drug Coverage Under Part A, Part B and Part D