Medicare Part D

The ABCs of Medicare Part D for IV and Injectable Therapies

What Medicare Part D includes

• Prescription Drug Coverage for all people with Medicare.
• The Prescription Drug Plan (PDP) and Medicare Advantage Prescription Drug Plan (MA-PDP).
• Extra help for people with limited incomes.

Coverage is not automatic

• Coverage began Jan. 1, 2006 for those who enrolled.
• May 15, 2006 is the last day for the initial enrollment period.
• June 1, 2006 is facilitated enrollment for people entitled to extra help.

Note: If a drug or service was previously covered under Medicare Part B, it is still covered under Medicare Part B.

How Medicare Part D affects coverage of injectable and infusion therapies

• Medicare Part D was not designed with injectable and infusion therapies in mind.
• Only specific drugs are covered.
• It does not cover services, including:
  • IV and enteral administration supplies.
  • Pharmacists, pharmacy techs, nursing and care coordinators.
  • Delivery, customer service, billing and collection and management personnel.
  • Space rental and other overhead costs.
• It does not cover off-label uses of drugs.
• Patients will incur out-of-pocket expenses for copays and/or administration supplies.

Drugs that are covered

• Prescription drugs, biologicals and insulin
• Medical supplies associated with insulin injection
• Cancer medications, HIV/AIDS treatments, antidepressants, antipsychotics, anticonvulsive treatments and immunosuppressants

Drugs that are not covered

• Drugs for anorexia, weight loss or weight gain; fertility; cosmetic purposes or hair growth; relief of cough and colds
• Prescription vitamins and minerals (except prenatal vitamins and fluoride preparations)
• Non-prescription drugs
• Barbituates and benzodiazepines
• Alternates to non-formulary drugs:
  • If the patient has coverage under Medicare and Medicaid, he or she is eligible to change the plan in 30 days.
  • A drug with the same therapeutic levels in the formulary can be prescribed.
  • The patient can initiate an appeal for the non-formulary drug.

Changes in the patient referral process

• Verification of patient eligibility can take up to 24 hours due to extreme hold times with payors.
• For non-formulary drugs, approval can take up to 72 hours after a Letter of Medical Necessity is faxed.

OptionCare can help you by...

• Determining your patients' eligibility and coverage for Part D home infusion services.
• Communicating with you throughout the patient verification process.
• Working through the complexities of Medicare Part D to ensure your patients understand their options and receive needed infusion services.
• Providing IV and injectable therapies and services to your Medicare patients, as well as to your other patients who need care outside the hospital setting.

Resources for you and your patients:

www.medicare.gov
US government web site for people with Medicare

www.shiptalk.org
Or call your local State Health Insurance Assistance Program

www.cms.hhs.gov/medlearn/provtoolkit.pdf
Toolkit for healthcare professionals

www.cms.hhs.gov/medlearn/drugcoverage.asp
Information for providers

Medicare information hotline
1-800-MEDICARE (TTY 1-877-486-2048)