THE BASICS: PART A & PART B DRUG COVERAGE
Part A: Hospital
Part A is the most basic tier of Medicare and covers certain hospitalization expenses, including drugs administered only during covered hospital stays.
Part B: Medical
Medicare Part B covers some of the expenses of preventative and outpatient care not covered under Part A. While Part B will help cover drugs deemed medically necessary by a physician for a patient’s treatment, drug costs are applied to the policy holder’s deductible before Medicare pays its portion of any drug expenses.
Note: The following is not a comprehensive list of drugs for which Part B will cover expenses, but some examples of what Part B will help cover.
- 1 flu shot per season. This typically means 1-2 per calendar year.
- Pneumococcal shots. For the prevention of certain strains of pneumonia as prescribed by the patient’s physician.
- Hepatitis B shots. A series of 3 Hepatitis B shots are covered if a doctor advises that the patient is at a medium to high risk of contracting Hepatitis B.
- Other shots if they are coded as medically necessary. Part B will cover shots if they are directly related to an injury or illness and required by the patient’s physician.
Durable Medical Equipment (DME) supply drugs: Drugs administered through equipment like an infusion pump or a nebulizer.
- Injectable and infused drugs. Part B usually covers drugs administered by a licensed medical provider if they are considered medically necessary and cannot be self-administered.
- Immunosuppressive drugs. Medicare covers immunosuppressive drug therapy for people who had a Medicare-covered organ transplant.
- Oral cancer drugs. Part B will cover some oral cancer drugs if the medication is also available in an injectable form or if the drug is required along with an infusion or injection, like anti-nausea drugs.
- Parenteral and enteral nutrition (intravenous and tube feeding). Part B will help cover the costs of certain medications and nutrients for patients who are unable to absorb or ingest nutrients without medical intervention.
PRESCRIPTION DRUG COVERAGE: MEDICARE PART D
Medicare Part D pays a portion of all expenses for drugs that are not covered under Part A or B and meet all of the following criteria:
- FDA-approved and sold in the USA.
- Available via prescription only.
- Used in an acceptable manner as defined by the SSA.
- Included in the plan’s list of covered drugs or approved through the plan’s exceptions and appeals process.
While Medicare must cover certain basic services, insurance coverage varies on a claim-by-claim basis. Client’s should consult Medicare (or their private health insurance company) directly regarding questions about specific drugs and procedures.
Medicare Part D is only available through private plans, and its vital that you encourage clients to enroll in a Part D plan as soon as they are eligible to prevent them from having to pay higher premiums down the road. Be prepared to offer your clients prescription drug coverage when they’re Medicare eligible and get contracted with Savers Marketing today!