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Part B Coverage Categories

Part B Coverage Categories

Medicare Part B Covered

This table provides a reference guide for the most frequent Part B/D coverage determination scenarios facing Part D plans and Part D pharmacy providers. It does not address all potential situations. For more extensive discussion, please refer to the Medicare Part B vs. Part D Coverage Issues document available at: http://www.cms.hhs.gov/PrescriptionDrugCovGenIn/Downloads/PartBandPartDdoc_07.27.05.pdf

The drugs listed below are covered for all members enrolled in a HealthPartners Medicare benefit plan, including those without a pharmacy benefit. Coverage of most of these drugs is federally mandated by CMS under Part B benefits for a specific patient diagnosis. Many of these medications require prior approval in order to verify the specified patient diagnosis listed below with each Part B covered class of medications. If a member does not meet the criteria for Part B coverage (all other covered uses), the will then be covered under the member’s Part D (or employer group, whichever is applicable) benefit if the drug is on the formulary or if the non-formulary drug is prior approved for coverage. These drugs are referred to as Part D Crossover drugs in this document.

Providers are strongly encouraged to write the following information on the prescription order for beneficiaries receiving medications that may be covered under Part B in order to determine Part B or Part D coverage: 1) Patient Diagnosis; 2) Dispensing Pharmacy Information (see Products Administered in DME via Nebulizer or via Infusion pump for coverage criteria by administration site, e.g., nursing home vs. beneficiary home); 3) Concurrent Medications as in the case of some oral anti-emetics, e.g. Emend (see Anti-emetics, Oral for specific coverage information needed on the prescription).

Providers must call HealthPartners Pharmacy Customer Service at 952-883-5813 or 1-800-492-7259 option 2, to request prior authorizations for applicable drugs.

Category & Coverage Criteria Medications/Products Additional Coverage Information

Anti-, Oral (Myleran) PA NOT Required, except for drugs flagged (Xeloda) with a single asterisk which require a PA to Part B Coverage Criteria: Oral drugs * (Cytoxan) - PA determine Part B or Part D coverage. used for cancer treatment that contain (Vepesid) the same active ingredient and are used (Alkeran) Part D Crossover Drug: Drugs flagged with for the same indications as Part B- ** asterisks will be covered under Part D when covered drugs furnished (Temodar) prescribed for any other FDA- approved incident to a physician’s service (such indication. as injectable dosage forms that are not usually self-administered). All drugs (except those flagged with asterisks) will auto process under Part B.

**Methotrexate tablet will always auto process under Part D and will require a manual entry to process under Part B when applicable.

Typically provided as out patient. Billed online by pharmacy.

Anti-emetics, Oral Aprepitant (Emend) PA Required to determine Part B or Part D (Thorazine) coverage. Part B Coverage Criteria: If oral anti- Diphenhydramine (Benadryl) Note: CMS requires physicians to indicate on emetic is used as full therapeutic (injection & prescription the prescription that the oral anti-emetic is replacement for intravenous (IV) anti- only 50mg capsule) being used as full therapeutic replacement for emetic drugs within 48 hours after IV Dolasetron (Anzemet) - NF the intravenous (IV) anti-emetic drug as part of chemotherapy administration. Dronabinol (Marinol) a cancer chemotherapeutic regimen. Granisetron (Kytril) Hydroxyzine Pamoate (Vistaril) Part D Crossover Drug: If a drug in this Ondansetron (Zofran) category is prescribed: (i) beyond 48 hours of IV Perphenazine (Trilafon) chemotherapy administration; or (ii) for any Prochlorperazine (Compazine) other approved indication not covered under Part Promethazine (Phenergan) B (non-chemotherapy-associated use), the drug will be covered under the beneficiary’s Part D prescription benefit.

Typically provided as out patient. Billed online by pharmacy.

Updated 03/13/2013 Page 1 of 8 Medicare Part B Covered Medications

Category & Coverage Criteria Medications/Products Additional Coverage Information

Antigens Serums PA NOT Required. Other Antigens Part B Coverage Criteria: Prepared by a Note: Never Part D physician and administered by a physician or Provided in clinic. Billed as a physician’s nurse. In some cases, the medical benefit / claim. physician prepares the antigens and furnishes them to a patient.

Blood Clotting Factors Anti-inhibitor Coagulation Factor PA NOT Required. Factor VIIa Part B Coverage Criteria: Approved for Factor IX Note: Never Part D Hemophilia or Von Willebrand’s Disease. If provided in clinic, billed as a Coverage includes items associated with the medical benefit / claim. administration of clotting factors. If provided as out patient, billed online by specialty pharmacy.

Diabetic Supplies Blood Glucose Monitors PA NOT Required. Blood Glucose Test Strips Part B Coverage Criteria: Always covered Lancets Note: Never Part D under a beneficiary’s DME benefit. Lancet Devices If provided as out patient, billed

online by pharmacy.

If provided by DME vendor, billed as medical benefit / claim.

Drugs furnished “incident to” a Various injectable and IV drugs PA May or May NOT be Required. physician service administered in a physician’s office Determine PA status by review of Medical Policy for a particular drug.

Part B Coverage Criteria: Injectable / Note: Only a physician office will bill Intravenous drugs (i) administered “incident Part B for drugs “incident to” a to” a physician service and (ii) considered by physician’s service. Exception: If Part B carrier (HealthPartners) as “not usually HealthPartners does not cover an self - administered”. injectable medication in the clinic and

it is Part D eligible, it must be covered under Part D.

Provided in clinic. Billed as a medical benefit / claim.

If denied medical coverage and Part D eligible, billed on-by pharmacy

Erythropoietin (EPO) Darbepoetin alfa (Aranesp) - PA for PA Required to determine Part B or cancer indication only Part D coverage. Part B Coverage Criteria: Treatment of Epoetin alfa (Epogen) - NF for a beneficiary with chronic renal Epoetin alfa (Procrit) – PA for Part D Crossover Drug: If prescribed failure (CRF) and who is undergoing . cancer indication only for any other approved indication not

covered under Part B, the drug will be Erythropoietin may also be covered under Part covered under Part D. B “Incident To” a Physician’s Service. If provided in clinic, billed as a medical benefit / claim.

If provided as out patient, billed

online by pharmacy.

Updated 03/13/2013 Page 2 of 8 Medicare Part B Covered Medications

Category & Coverage Criteria Medications/Products Additional Coverage Information

Immunosuppressant Drugs (Azasan) PA Required to determine Part B or Part Azathioprine (Imuran) D coverage, except for drugs flagged Part B Coverage Criteria: Drugs used in Belatacept (Nulojix) with an asterisk. Clinical PA also immunosuppressive therapy for beneficiaries Cyclophosphamide (Cytoxan) required for drugs flagged with a PA. that receive a Medicare Covered Transplant. Cyclosporine (Sandimmune/Neoral) (Zortress) - PA Part D Crossover Drug: Drugs will be *Methotrexate tablet covered under Part D when prescribed Methotrexate injection for any other FDA- approved indication. Methylprednisolone (Medrol) Mycophenolate Acid (Myfortic) - NF *Methotrexate tablet will always auto Mycophenolate Mofetil (Cellcept) process under Part D and will require a Prednisolone manual entry to process under Part B when applicable. Prednisone (Rapamune) Typically provided as out patient. (Prograf) Billed online by pharmacy. Tacrolimus (Hecoria) - NF

Insulin Supplies Swabs PA NOT Required. Gauze Part B Coverage Criteria: None Insulin Needles Note: Never Part “B”

Insulin Pen Device Part D Coverage Criteria: Supplies

Insulin Syringes related to the use of Insulin are always covered under Part D.

Provided as out patient. Bill online by pharmacy.

All total parenteral nutrition (TPN) PA NOT Required. Parenteral Nutrition and its components (amino acids, Note: Parenteral nutrition drug components Part B Coverage Criteria: Prosthetic dextrose, lipids, standard TPN of TPN are covered under Part D (not Part B) benefit for individuals with “permanent” additives) – NF if patient has a functioning GI tract whose dysfunction of the digestive tract. If medical need for parenteral nutrition is due to: record, including the judgment or the Included in Part B Coverage: • A swallowing disorder attending physician, indicates that the IV vitamins • A temporary defect in gastric emptying impairment will be long and indefinite Trace elements/minerals such as a metabolic or electrolyte disorder duration, the test of permanence is met. Sole Supplies and equipment for • A psychological disorder impairing food source of nutrition. Use of TPN for a administration intake such as depression minimum of 90 days. • A metabolic disorder inducing such as cancer Freamine III • A physical disorder impairing food intake Intralipid 20% & 30% such as the dyspnea of severe pulmonary or cardiac disease • A side effect of a medication • Renal failure and/or dialysis

Part D does not pay for: i) multivitamin and trace / elements added to the solution; or ii) the equipment / supplies and professional services associated with the provision of parenteral nutrition.

NOTE: and chloride flush are covered under a member’s HealthPartners DME benefit. They are not covered under Part B or Part D.

If provided in clinic, bill as a medical benefit / claim.

If provided as out patient, bill online by pharmacy. Updated 03/13/2013 Page 3 of 8 Medicare Part B Covered Medications

Category & Coverage Criteria Medications/Products Additional Coverage Information

Products Administered in Durable (Mucomyst) PA NOT Required. Medical Equipment (DME): Arformoterol tartrate (Brovana) – NF Albuterol Part D Crossover Drug: If an Nebulized Drugs Only inhalation drug that requires (Proventil/Ventolin/Accuneb) Part B Coverage Criteria: Inhalation Albuterol/Ipratropium (DuoNeb) administration via a nebulizer (covered drugs that required for a Part B-covered Budesonide DME) because the beneficiary resides DME to perform its function at home. (Pulmicort Respule) in a long term care (LTC) facility or These drugs are administered via a Cromolyn sodium (Intal) nursing home (not their “home”) the nebulizer (covered DME) only for Dornase alfa (Pulmozyme) drug will be covered under the beneficiaries residing in their “home”. Formoterol fumarate beneficiary’s Part D prescription (Perforomist) – NF benefit. Note: In addition to a hospital, a skilled Iloprost (Ventavis) – PA (specialty) nursing facility (SNF) or a distinct part Will auto process under Part B Ipratropium (Atrovent) SNF, the following long term care coverage for beneficiaries residing in Levalbuterol hcl (Xopenex) – NF facilities (LTC) cannot be considered a their home. Pentamidine isethionate home for purposes of receiving the (Nebupent) – NF Will auto process under Part D Medicare Part B DME benefit: Racepinephrine (AsthmaNefrin)– NF coverage for beneficiaries residing in

Ribavirin (Virazole) – NF an LTC facility or nursing home. • A nursing home that is dually- Tobramycin (TOBI) certified as both a Medicare If provided in clinic, billed as a Treprostinil (Tyvaso) – PA (specialty) SNF and a Medicaid nursing medical benefit / claim.

facility (NF) If provided as out patient or in LTC, • A Medicaid-only NF that billed online by pharmacy. primarily furnishes skilled care; • A non-participating nursing home (i.e. neither Medicare nor Medicaid) that provides primarily skilled care; and • An institution which has a distinct part SNF and which also primarily furnishes skilled care.

Updated 03/13/2013 Page 4 of 8 Medicare Part B Covered Medications

Category & Coverage Criteria Medications/Products Additional Coverage Information

End Stage Renal Disease ALWAYS ESRD Drugs: PA Required to determine Part B or (ESRD) Drugs Part D coverage. Access Management: Drugs used to Part B Coverage Criteria: ensure access by removing clots from Part D Crossover Drug: CMS implemented a system to permit grafts, reverse anticoagulation if too much Process under Part B if an individual is reporting of ESRD dialysis start and end dates medication is given and provide anesthetic flagged as an ESRD patient receiving one on the enrollment transaction reply report and for access placement. of these medications from an ESRD as necessary thereafter to report changes in the Heparin injection & IV facility and has a dialysis start date. ESRD information. This ESRD information Lidocaine injection should be used to determine whether or not an (5mg/ml & 10mg/ml) Process under Part D if an individual is not ESRD beneficiary is receiving renal dialysis Lidocain-Prilocaine cream flagged as an ESRD patient. services. It is not sufficient to confirm the ESRD indicator alone, but a dialysis start date Anemia Management: Drugs use to If provided at an ESRD facility: Billed is also necessary. stimulate red blood cell production. as a medical benefit / claim for bundled Darbepoetin (Aranesp) - PA services provided by the ESRD facility. Questions for Payment Determination: Epoetin Alfa (Procrit) - PA Epogen - NF If provided for individuals who are not 1. Does the prescriber (i.e., nephrologist, flagged as ESRD: Billed online by nurse practitioner, or physician assistant) Anti-Infectives: Drugs to treat access site pharmacy. receive a monthly capitation payment or . manage ESRD patient care? Vancomycin injection Daptomycin injection - NF a. If Yes, ask question #2. b. If No, the drug is not ESRD-related. Bone and Mineral Metabolism: Drugs Confirm the prescriber’s NPI and used to prevent/treat bone disease proceed with any further Part D secondary to dialysis. processing. Calcitriol capsule & solution Calcitriol IV (Calcijex) - NF 2. Is the drug prescribed to be used for an gluconate IV - NF ESRD-related condition? Calcium salmon injection - NF Calcium salmon nasal - PA a. If Yes, the drug is ESRD-related and not Deferoxamine injection - NF covered under Part D. Doxercalciferol IV (Hectoral) - NF b. If No, the drug is not ESRD-related. Ibandronate injection & tablet Confirm the prescriber’s NPI and (Boniva) - NF proceed with any further Part D Pamidronate IV (Aredia) - NF processing. Paricalcitol capsule (Zemplar) - PA Paricalcitol IV (Zemplar) - NF If HealthPartners determines later that the ESRD facility should have been paid instead Cellular Management: Drugs used for of processing under Part D, the sponsor must deficiencies of naturally occurring recover the Part D payment and reverse the substances needed for cellular PDE. Beneficiaries should be directed to the management. ESRD facility to recover any cost-sharing Levocarnitine solution & tablet incurred on the claims. Drugs that MAY be ESRD-related:

Antiemetics: Prevent or treat and secondary to dialysis. Ant-infectives (may include antibacterial and drugs): Treat infections. Antipruritic: Treat itching related to dialysis. Anxiolytic: Treatment of restless leg syndrome secondary to dialysis. Excess Fluid Management: Treat fluid excess/overload. Fluid and Electrolyte Management: IV drugs/fluids used to treat fluid and electrolyte needs. Pain Management: Treat graft site pain and to pain medication overdose.

Updated 03/13/2013 Page 5 of 8 Medicare Part B Covered Medications

Category & Coverage Criteria Medications/Products Additional Coverage Information

Products Administered in Durable Chemotherapy – for primary PA Required for all drugs in this Medical Equipment (DME): IV Hepatocellular or colorectal class to determine Part B coverage Drugs and Insulin “requiring a Carcinoma (beneficiaries residing in their pump for infusion” home) or Part D coverage Deferoxamine – for chronic (beneficiaries residing in an LTC Part B Coverage Criteria: IV drugs and Overload facility or nursing home). Insulin that require administration via pump for infusion (covered DME) only Insulin, continuous subcutaneous – Part D Crossover Drug: If an IV for beneficiaries residing in their for diabetes mellitus drug or insulin requires administration “home”. via a pump for infusion (covered Morphine - for cancer related pain DME) because the beneficiary Note: In addition to a hospital, a skilled resides in a long term care (LTC) nursing facility (SNF) or a distinct part Other Drugs – administered by a facility or nursing home (not their SNF, the following long term care prolonged infusion of at least 8 “home”) the drug will be covered facilities (LTC) cannot be considered a hours due to proven clinical under the beneficiary’s Part D home for purposes of receiving the prescription benefit. efficacy Medicare Part B DME benefit: If provided in clinic, billed as a medical benefit / claim. • A nursing home that is dually- certified as both a Medicare If provided as out patient or for SNF and a Medicaid nursing beneficiaries who reside in LTC, facility (NF) billed online by pharmacy. • A Medicaid-only NF that primarily furnishes skilled care; • A non-participating nursing home (i.e. neither Medicare nor Medicaid) that provides primarily skilled care; and • An institution which has a distinct part SNF and which also primarily furnishes skilled care.

Updated 03/13/2013 Page 6 of 8 Medicare Part B Covered Medications

Category & Coverage Criteria Medications/Products Additional Coverage Information

Prophylactic (Preventive) Vaccines Hepatitis B PA Required to determine Part B or Influenza Part D coverage. Part B Coverage Criteria: Vaccines Pneumococcal given directly related to the treatment of Rabies Part D Crossover Drug / Coverage an injury or direct exposure to a disease Tetanus Critera: or condition are always covered under Other vaccines/toxoids directly Vaccines NOT related to the treatment Part B. related to treatment of an injury or of an injury or direct exposure to a direct exposure to a disease or disease or condition are covered under Hepatitis B for intermediate and high risk condition Part D. patients are always Part B. Hepatitis B vaccine for low risk • Hepatitis B Vaccine High Risk: individuals should be considered for individuals w/ESRD, clients of coverage under Part D. institutions for individuals for the mentally handicapped, persons who Influenza & Pneumococcal vaccines are Never covered under Part D. live in the same household as a hepatitis B virus carrier, homosexual Provided in clinic. Billed as a men, illicit injectable drug users, medical benefit / claim. individuals with hemophilia who receive Factor VIII or IX.

• Hepatitis B Vaccine Intermediate Risk: 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.

Influenza and Pneumococcal vaccines are always covered under Part B.

• Influenza is covered under Part B per applicable state law and beneficiaries may receive the vaccine upon request.

Updated 03/13/2013 Page 7 of 8 Medicare Part B Covered Medications

Category & Coverage Criteria Medications/Products Additional Coverage Information

Miscellaneous Medications Antifungal/Antiviral Drugs PA May or May NOT be Required. (Injectables/Infusion Drugs) Acyclovir Amphotericin B - PA Part D Coverage Criteria: Liposomal amphotericin B only If any of the listed medications are Part B Coverage Criteria: See covered for patients who have administered for any other diagnosis than medications/products column for criteria. have suffered significant toxicity those listed for Part B, they will fall under with standard amphotericin B or Part D coverage. Infusion by pump, IV push, IV drip or significantly impaired renal function injectable medications administered in a Foscarnet - PA Infusion by pump, IV push, IV drip or physician’s office are always covered Ganciclovir - NF injectable medications administered in the under Part B. patient’s home, long term care facility Chemotherapy Drugs - All PA (LTC) or a nursing home are covered under Part D unless otherwise stated.

Cladribine IV hydration and IV antibiotics are (non-liposomal) covered under Part D, NOT Part B. Any other medications administered via a pump outside of the physician’s office will fall under Part D. See Products Administered in Durable Medical Chronic Pain, severe Equipment (DME) – IV Drugs and Insulin Ziconotide (Prialt) - NF “requiring a pump for infusion” section.

Hypercalcemia (cancer-related) Part D does not pay for the Gallium nitrate - NF equipment/supplies and professional services associated with the provision of IVIG Provided in the Home - PA IV medications. Diagnosis of primary immune deficiency disease New injectable medications should be Coverage under Part B if physician covered under Part D until carrier determines that administration in (HealthPartners) or CMS determine the the patient’s home is medically new injectable is covered under Part B. necessary Part B coverage is limited to the NOTE: Heparin and IVIG only (not supplies/equipment) flush are covered under a member’s Administration in the home for other HealthPartners DME benefit. They are indications in accordance with not covered under Part B or Part D. FDA approval or compendium listing is a Part D benefit. If provided in clinic, billed as a medical benefit / claim. Narcotic Analgesics for Cancer Pain Narcotic analgesics (except If provided as out patient or in LTC, meperidine) in place of billed online by pharmacy. morphine for intractable cancer

Parenteral Inotropic Drugs For patients with CHF Dobutamine - NF Dopamine - NF Milrinone - NF

Pulmonary Hypertension Treatment Epoprostenol (Flolan) - PA Treprostinil (Remodulin) - PA

Updated 03/13/2013 Page 8 of 8

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