News & Articles A, B or D? Understanding the Medicare Alphabet One of the (many) challenges of Medicare medication management is determining if a medication is covered under part B or part D. This is especially tricky for some medication as they can be either B or D depending on the situation. Read on for more: Generally speaking, Part A can be considered hospital insurance. It pays for medications related to Part A services: a hospital stay, a Medicare stay in a skilled nursing facility, or drugs used in hospice care for symptom control or pain relief. Part B can be considered a Medical insurance: generally covers medications that cannot be self-administered and that are administered by or under the supervision of a physician in the physician’s office. The introduction of Part D did not change the coverage of any Part B benefits. Therefore what was covered by Part B prior to Part D would still be a Part B covered benefit. Part B coverage follows specific CMS requirements that could involve all of the following: type of medication, place of service, who administers the service, the diagnosis of the patient, in relationship with other medications provided and meeting diagnostic and laboratory requirements. Examples of Part B covered medications: oral anti-cancer drugs, some oral anti-nausea medications, hemophilia clotting factors, drugs furnished by dialysis facilities, drugs furnished as part of an outpatient procedure, flu, pneumonia, and Hepatitis B vaccines etc… Part D is considered prescription drug insurance: Medications not covered as Part A, Part B or not excluded by Medicare part D can be considered a Part D covered benefit. Covered drugs include prescription drugs, biological products, insulin, insulin injection supplies and some vaccines. Medications excluded from Medicare part D include, but are not limited to: medications used for weight loss, for fertility treatment, for cosmetic purposes, barbiturates and some anxiety or sleep aid medications called benzodiazepines. Cough and cold medications as well as over-the-counter medications are also excluded. Some medications can be either Part B or D depending on the situation: Care1st Medicare Drug Formulary is required to list any potential Part D covered benefits. All drugs that could be a Part B benefit require a prior authorization for coverage. Prior Authorization guidelines will determine if a request is a Part B or Part D benefit. The co-pay tiers reflected on the formulary would apply if the drug is determined to be a Part D benefit, those drugs determined to be a Part B benefit will be subject the Part B co-payment/co-insurance as reference in the members evidence of coverage. The majority of injectables, listed in the formulary -other than insulin- will require a Part B versus Part D determination. Below are some examples of oral medications that require a Part B versus Part D determination: 1. Immunosuppressive Drugs: Drugs used in immunosuppressive therapy (such as cyclosporine, Cellcept…) for a beneficiary who has received a Medicare covered organ transplant are covered under part B. If used for another condition not related to an organ transplant would be considered a Part D benefit. 2. Oral Anti-emetic Drugs: Oral anti-nausea drugs used as part of an anti-cancer chemotherapeutic regimen as a full therapeutic replacement for an intravenous anti-emetic drug within 48 hours of chemotherapy administration, are Part B benefits. 3. Oral Chemotherapeutic Drugs: Oral chemotherapy agents will be a Part B benefit if an injectable version of the drug exists. If the drug is used to treat something other than cancer, it could be a Part D benefit. In Conclusion: due to the fact that a drug may be covered as either part B or D benefit, it is important to let members know to check with their doctor or Care1st to determine their cost share.