Medicare Advantage Part B

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.