Ask the Pharmacist

What is the best way to determine if a drug should be billed under Medicare Part B or Part D? Can Pharmastar assist with this process?

Pharmastar can definitely help with this process! In general, Medicare Part D covers most self-administered drugs like tablets, suspensions, self-injections, insulins, etc. Medicare Part B covers most drugs that would typically be administered in a hospital or clinic by a health care provider in addition to a couple of specific drug classes. Making appropriate Medicare Part B versus D determinations is important, and Pharmastar understands the intricacies involved. To streamline the process for our clients, Pharmastar provides a Medicare Part B vs. D report. We have identified specific drugs that may require a B vs. D determination, and we share a list of these drugs and the patients taking them with the plan sponsor. The plan sponsor views the list of drugs, answers a question that helps determine Part B vs Part D status, and then redacts PDEs for the drugs determined to be Part B. This is a retrospective way that Pharmastar assists plan sponsors with compliant billing practices.

Are there any continuous glucose monitors (CGMs) that are covered by Medicare Part D?

Currently no, CGMs covered by Part D. CGMs are considered durable medical equipment, so they are covered under Medicare Part B. Some of the most prescribed CGMs are Dexcom® and FreeStyle Libre®. Both of these offer continuous blood glucose readings for patients with diabetes. They differ in how they are used, and patients may prefer to use one CGM over another. For most plan sponsors, FreeStyle Libre® may be the more cost-effective option.

How can we ensure that the Medicare Part D drugs used to treat our participants meets CMS’s criteria for a medically accepted indication?

The Medicare Prescription Drug Benefit Manual (Chapter 6) defines medically accepted indications. Part D sponsors should ensure, to the best of their ability, that covered Part D drugs are being used for medically accepted indications, which include the drug’s FDA approved indication. To find a drug’s FDA approved indication, you can search the FDA’s website for the drug’s most current package insert. In addition to the FDA approved indication, other indications may be covered if they are supported in the following compendia: American Hospital Formulary Service Drug Information and DRUGDEX® Information System. Both compendia require a fee for access. To streamline this process for our clients, Pharmastar provides a monthly Medical Necessity Report. The report identifies drugs and drug classes that CMS has suggested could be targeted during audits for appropriate use. Additionally, the report generates a specific question to be answered by the plan’s clinical staff to help determine whether a medication is being used for a medically accepted indication. Pharmastar has access to the recognized compendia and continuously updates the drugs listed on the report.