Notification



Notification Issue Date:



Policy Attachment

Attachment to Policy # MA08.007q


Attachment:A

Policy #:MA08.007q

Description:Part B drugs that can be accessed through the Part D pharmacy benefit: pharmacy claims process at Medicare Part B cost share with no true out-of-pocket (TrOOP) expenses applied

Title:Medicare Part B vs. Part D Crossover Drugs

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.


MEDICARE MEDICAL BENEFIT (PART B) DRUGS THAT CAN BE ACCESSED AT A RETAIL OR LONG-TERM CARE PHARMACY SETTING. CLAIMS FROM A RETAIL OR LONG-TERM CARE PHARMACY PROCESS AT A MEDICAL BENEFIT (PART B) COST SHARE WITH NO PHARMACY BENEFIT (PART D) TRUE-OUT-OF-POCKET (TROOP) EXPENSES APPLIED

  • Diabetic glucometers, test strips, lancets, lancing devices, gauze bandages (except 2x2"), blood ketone strips and glucose control solutions
  • Heparin and saline flushes
  • Oral chemotherapy with intravenous (IV) equivalents:
    • Busulfan (Myleran®) 2 mg
    • Capecitabine (Xeloda®) 150 mg, 500 mg
    • Etoposide (VePesid®) 50 mg
    • Melphalan (Alkeran®) 2 mg
    • Cyclophosphamide (Cytoxan®) 25 mg, 50 mg
    • Topotecan (Hycamtin®) 0.25 mg, 1 mg
    • Temozolomide (Temodar®) 5 mg, 20 mg, 100 mg, 140 mg, 180 mg, 250 mg
  • Oral anti-emetic drugs
    • Oral ondansetron
    • Oral granisetron
    • Emend
  • Immunosuppressants
    • Azathioprine (Azasan®, Imuran®)
    • Basiliximab (Simulect)
    • Belatacept (Nulojix®)
    • Cyclosporine (Gengraf®, Neoral®, Sandimmune®)
    • Everolimus (Zortress®)
    • Lymphocyte immunoglobulin
    • Methotrexate
    • Methylprednisolone
    • Mycophenolate (Cellcept®, Myfortic®)
    • Prednisolone
    • Prednisone
    • Sirolimus (Rapamune®)
    • Tacrolimus (Astagraf®, Prograf®)
  • Inhaled nebulized solutions
    • Acetylcysteine (Mucomyst®)
    • Albuterol
    • Albuterol and ipratropium (DuoNeb™)
    • Albuterol sulfate (AccuNeb®)
    • Arformoterol tartrate (Brovana™)
    • Budesonide inhalation suspension (Pulmicort Respules®)
    • Cromolyn (Intal®)
    • Dornase alfa (Pulmozyme®)
    • Formoterol Fumarate (Perforomist)
    • Iloprost (Ventavis®)
    • Ipratropium
    • Levalbuterol hydrochloride (Xopenex®)
    • Pentamidine Isethionate (Nebupent®)
    • Sodium Chloride for Inhalation
    • Treprostinil Inhalation Solution (Tyvasco®)
    • Tobramycin Inhalation Solution (TOBI®)
    • Tobramycin nebulized solution (Bethkis®)


Version Effective Date: 01/01/2020
Version Issued Date: 12/31/2019
Version Reissued Date: N/A

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