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Medicare Advantage Part B

Provider Type

  • Physicians (does not apply to Cal MediConnect)
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

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.
    • 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.

Self-Injectable 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.

Last Updated: 10/30/2019