Medicare Advantage Part B
- Physicians (does not apply to Cal MediConnect)
- Participating Physician Groups (PPG)
Part B Prescription Medication
Health Net may delegate utilization management (UM) for Part B prescription medications to a participating physician group (PPG). Part D covers a broad range of prescription medications, biologicals, vaccines, and insulin, but it does not change current Centers for Medicare & Medicaid Services (CMS) coverage policies under Part B. Some prescription medications, biologicals and vaccines continue to be covered under Medicare Part A or Part B. New medications entering the market meeting the definition of medications covered under Part B become part of the Part B benefit, rather than the Part D benefit.
Part B Coverage
Part B prescription medication coverage is as follows:
- Injectable or intravenous (IV) prescription medications that are administered predominantly by a physician or under a physician's direct supervision as "incident to" a physician's professional service.
- Medications administered "incident to" a physician's service that are usually not self-administered
- According to CMS, if a medication is self-administered by fewer than 50 percent of Medicare beneficiaries it is considered "not usually self-administered." Determination is made on a case-by-case basis and depends on several factors, including the method, chronicity and frequency of administration.
- Erythropoietin for members with anemia with chronic renal failure who are on dialysis.
- Antigens prepared by a prescriber and administered in the prescriber's office or self-administered by a member who has been appropriately trained.
- IV immune globulin provided in the home setting for members diagnosed with primary immune deficiency.
- Infusion therapies in the home that have been designated by Medicare as requiring the use of an infusion pump (an item of durable medical equipment (DME)).
- Parenteral nutrition provided in the home due to a non-functioning digestive tract
- Inhaled medications administered through a nebulizer.
- Hemophilia clotting factor administered in home to hemophiliac members capable of using the clotting factor without medical supervision in order to control bleeding.
- Certain vaccines, including:
- Pneumococcal vaccine, if ordered by a prescriber.
- Influenza vaccine when furnished in compliance with applicable state law.
- Hepatitis B vaccine if the beneficiary is at high or intermediate risk of contracting the disease, such as:
- High-risk groups, including:
- Individuals with end-stage renal disease (ESRD).
- Individuals with hemophilia who received factor VIII or IX concentrates.
- Clients of institutions for the mentally handicapped.
- Persons who live in the same household as a hepatitis B virus (HBV) carrier.
- Homosexual men.
- Illicit injectable medication users.
- Intermediate-risk groups, including:
- Staff in institutions for the mentally handicapped.
- Workers in health care professions who have frequent contact with blood or blood-derived body fluids during routine work.
- Other vaccines (such as tetanus toxoid) when directly related to the treatment of an injury or direct exposure to a disease or condition.
- High-risk groups, including:
- Medications packaged under the hospital outpatient prospective payment system.
- Prescription medications furnished as a part of a service in provider settings
- Medications furnished by ESRD facilities and included in Medicare's ESRD composite rate.
- Osteoporosis medications provided by home health agencies under certain conditions.
- Medications furnished by critical access hospitals' (CAHs') outpatient departments.
- Medications furnished by rural health clinics (RHCs).
- Medications furnished by federally qualified health centers (FQHCs).
- Medications furnished by community mental health centers (CMHCs).
- Medications furnished by ambulances.
- Separately billable medications provided in comprehensive outpatient rehabilitation facilities (CORFs).
Refer to the CMS Medicare Part B vs Part D Coverage Summary on the CMS website for commonly prescribed medications.
Medications that can be self-administered are generally not covered by Medicare Part B. Self-administered medications are covered by Health Net under Medicare Part D . Examples of self-administered medications that are covered under Part B are blood clotting factors, medications used in immunosuppressive therapy, erythropoietin for members on dialysis, and osteoporosis medications for certain homebound members.