CASE FLASH: MEDICARE PART D VS. PART B COVERAGE (INJECTABLES)

Mrs. J has Original Medicare Parts A and B, as well as a stand-alone Part D prescription drug plan. Earlier this year, Mrs. J was hospitalized and diagnosed with anemia. The week after she left the hospital, Mrs. J went to a doctor’s appointment in the hospital, where she got a prescription for an injectable anemia medication. Mrs. J filled the prescription at the hospital pharmacy, paid a coinsurance, and gave herself the injection at home. A month later, however, Mrs. J received a Medicare Summary Notice (MSN) stating that Medicare would not pay for the anemia medication.

Mrs. J called the Medicare Rights Center and spoke with a hotline counselor about Medicare’s denial. The counselor pointed out that the letter Mrs. J received was from Medicare. This meant that Original Medicare (A and B) was refusing to pay for the medication.

The counselor looked up information about the particular medication and found that the anemia medication is sometimes covered by Part B and is sometimes covered by Part D. Whether Part B or Part D covers the medication for you depends on where you get the injection and who gives it to you. However, for people like Mrs. J, who self-administer the drug at home, the medication should be covered by the Part D prescription drug plan.

Together, the counselor and Mrs. J called the pharmacy at the hospital. The counselor explained that because Mrs. J self-administered the medicine at home, the bill should be submitted to her Part D plan. The pharmacist agreed to re-bill the medication to Mrs. J’s Part D plan and refund her the difference between the coinsurance she was charged and her plan’s copay. The Part D plan paid for the prescription, and Mrs. J was responsible only for her Part D plan’s copay for the medication.

-Adapted from MEDICARE WATCH, a biweekly electronic newsletter of the Medicare Rights Center, Vol. 11, No. 8, April 15, 2008.

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