2015 National Training Program
Medicare
Prescription Drug
Coverage Under
Part A, Part B, and
Part D
July 2015
Lesson 1—Inpatient Prescription Drug Coverage
 Inpatient status
 Medicare prescription drug coverage in
hospitals, skilled nursing facilities, and hospice
care
06/01/2015
Medicare Drug Coverage Under Part A, Part B, and Part D
2
Hospital Inpatient Status
 You’re an inpatient starting when you’re formally
admitted as an inpatient to a hospital with a
doctor’s order and you’re
• Expected to stay in the hospital 2 or more midnights
 The 2-midnight rule applies
o
Explains the standard for inpatient hospital stays
06/01/2015
Medicare Drug Coverage Under Part A, Part B, and Part D
3
Inpatient Hospital and Skilled Nursing
Facility (SNF) Prescription Drug Coverage
 Part A generally covers all drugs received as part of
treatment during a covered inpatient stay
• In a hospital or SNF
 Part B may pay hospitals and SNFs for certain categories
of Part B covered drugs if
• You don’t have Part A or your coverage has run out
• The stay isn’t covered by Part A
06/01/2015
Medicare Drug Coverage Under Part A, Part B, and Part D
5
Prescription Drug Coverage for Hospice Care
 Part A per-diem payments are made to the hospice to
cover all related patient-care needs
• Including drugs or biologicals
• Drugs that were used prior to the hospice election
are also covered if necessary for the palliation and
management of the terminal illness and related
conditions
 If covered under the Part A per-diem payment are
excluded from coverage under Part D
06/01/2015
Medicare Drug Coverage Under Part A, Part B, and Part D
6
Prescription Drug Coverage for Hospice Care—
Continued
 To be covered by Part D, the drug must be for
treatment of a condition that's completely unrelated
to the terminal illness or related conditions
• CMS expects that the occurrence of Part D covered
hospice drugs will be fairly uncommon, therefore

Hospices should communicate with Part D plans and
prescribers about drugs that should be considered for
coverage under Part D
o
06/01/2015
Voluntary standardized form “Hospice Information for
Medicare Part D Plans CMS-10538” and its instructions are
available on CMS' website
Medicare Drug Coverage Under Part A, Part B, and Part D
7
Lesson 2—Coverage of Vaccinations
 Overview of Medicare vaccination coverage
06/01/2015
Medicare Drug Coverage Under Part A, Part B, and Part D
8
Medicare Vaccination Coverage
 Part A covers vaccines that are administered for therapeutic
purposes when you are an inpatient
• E.g., a tetanus booster shot given to a SNF resident in response to an
actual exposure to the disease (if the SNF stay is covered by Part A)
 Part B covers vaccines that are preventive in nature whether you
are an inpatient or outpatient
• Must be in one of the 3 categories

Pneumococcal pneumonia

Hepatitis B*, or

Influenza
 Part D covers vaccines for which no Part B benefit category exists
• And aren’t be covered under Part A or B
*Your Hepatitis B (HBV) vaccine series would be covered under Part B if you’re at
high or medium risk for HBV. If you aren't at high or medium risk your HBV vaccine
series would be covered under Part D.
06/01/2015
Medicare Drug Coverage Under Part A, Part B, and Part D
9
Check Your Knowledge—Question 1
Pearl was given a tetanus shot
after being scratched by a rusty
nail. If she’s receiving Medicarecovered skilled nursing facility care
and has Original Medicare and Part
D, which part of Medicare will
cover the shot?
a.
b.
c.
d.
Part A
Part B
Part D
Her Medigap policy
06/01/2015
50%
50%
0%
a.
Medicare Drug Coverage Under Part A, Part B, and Part D
b.
0%
c.
d.
10
Check Your Knowledge—Question 2
Albert is receiving Medicare-covered
care in a skilled nursing facility and
was given a preventive poliomyelitis
vaccine. If he has Original Medicare
and Part D, which part of Medicare
will cover his poliomyelitis vaccine?
a.
b.
c.
d.
Part A
Part B
Part D
His Medigap policy
06/01/2015
Medicare Drug Coverage Under Part A, Part B, and Part D
50%
50%
0%
a.
0%
b.
c.
d.
11
Lesson 3—Outpatient Prescription Drug Coverage
 Outpatient status
 Medicare prescription drug coverage in
outpatient settings
06/01/2015
Medicare Drug Coverage Under Part A, Part B, and Part D
12
Hospital Outpatient Status
 You're an outpatient if the doctor hasn't written
an order to admit you to a hospital as an
inpatient, and you’re getting
• Emergency department services
• Observation services

The services you receive while in observation status
• Outpatient surgery
• Lab tests, or X-rays
• Any other hospital services
You are in observation status when you receive hospital outpatient services
while your doctor decides whether you’ll be admitted as an inpatient or
discharged.
06/01/2015
Medicare Drug Coverage Under Part A, Part B, and Part D
13
Outpatient Prescription Drug Coverage—Part B
 Part B covers limited outpatient drugs
• Generally, the drugs you wouldn’t usually give yourself

Unless required for hospital outpatient services you’re getting
• Most injectable and infusible drugs given as part of a doctor’s
service
• Drugs and biologicals used for the treatment of End-Stage Renal
Disease (ESRD)
• Drugs used at home with some types of Part B-covered
durable medical equipment (DME) such as nebulizers and
infusion pumps
• Some oral drugs with special coverage requirements like

Certain oral anti-cancer and oral antiemetic

Immunosuppressive drugs, under certain circumstances
06/01/2015
Medicare Drug Coverage Under Part A, Part B, and Part D
14
Immunosuppressive Drugs Under Part B
 Covered by Medicare Part B for people who were
entitled to Part A at the time of a kidney transplant
provided that the transplant was performed at the
Medicare approved facility and
• Medicare made payment for the transplant, or
• Medicare was secondary payer
 If you don’t meet the conditions for Part B coverage
• You may get coverage by enrolling in Part D

06/01/2015
Must be enrolled in Part B for Part D to cover these drugs
Medicare Drug Coverage Under Part A, Part B, and Part D
15
Self-Administered Drugs in
Hospital Outpatient Settings
 Part B doesn’t cover self-administered drugs in
a hospital outpatient setting
• Unless required for hospital outpatient services
you’re getting
 Part D may cover the self-administered drugs
you get in hospital outpatient settings
• If they’re not related to the services you’re getting
• You may have to pay out-of-pocket, then send a
claim to your Part D plan for reimbursement
06/01/2015
Medicare Drug Coverage Under Part A, Part B, and Part D
16
Coverage of Insulin
 Generally, Medicare Part B covers insulin used
with an infusion pump
 Medicare Part D Covers
• Injectable insulin not associated with the use of an
insulin infusion pump
• Inhaled insulin
06/01/2015
Medicare Drug Coverage Under Part A, Part B, and Part D
17
Case Scenario—1
Mary was taken to the ER with an injured leg and
remained in the hospital for one night.
While there, she was given Percocet and an
antibiotic injection for treatment related to her
injury, Maxalt for her chronic migraine, and
Losartan for hypertension.
Mary believes that there may have been a billing
error because Medicare only paid for some of her
drugs and she was charged for others.
She has Original Medicare and a Part D plan.
06/01/2015
Medicare Drug Coverage Under Part A, Part B, and Part D
18
Check Your Knowledge—Question 3
Based on the information
provided, what’s Mary’s hospital
status?
a. Inpatient
b. Outpatient
c. There isn’t sufficient
information to make a
determination
d. Requiring skilled level of care
0%
06/01/2015
a.
Medicare Drug Coverage Under Part A, Part B, and Part D
0%
0%
b.
c.
0%
d.
19
Check Your Knowledge—Question 4
If Mary was a hospital outpatient,
which of her prescription drugs
would Part B cover?
a. Maxalt and Losartan for treatment
of her chronic conditions
b. Percocet and the antibiotic
injection for treatment of her
broken leg
c. All of her drugs will be covered by
Part A
d. All of her drugs will be covered by
Part B
0%
a.
06/01/2015
Medicare Drug Coverage Under Part A, Part B, and Part D
0%
0%
b.
c.
0%
d.
20
Check Your Knowledge—Question 5
The charges that Mary received
were for the Maxalt and
Losartan which she was given
for treatment of her chronic
conditions. Which part of
Medicare should cover these
drugs?
a.
b.
c.
d.
Part A
Part B
Part D
Her Medigap policy
06/01/2015
0%
0%
a.
b.
Medicare Drug Coverage Under Part A, Part B, and Part D
0%
c.
0%
d.
21
Case Scenario—2
Pearl has Original Medicare and Part D. She is 73
with diagnoses of high blood pressure and EndStage Renal Disease.
After consulting with her doctor, he prescribed the
Hepatitis B vaccine series. Pearl went to her local
pharmacy for the first vaccine in the series.
06/01/2015
Medicare Drug Coverage Under Part A, Part B, and Part D
22
Check Your Knowledge—Question 6
Why did the pharmacy bill
Medicare Part B for Pearl’s
Hepatitis B vaccine?
a. Because Part B always
covers Hepatitis B
vaccines
b. Because Pearl is in the
“High-Risk” Category
c. In this case, it should’ve
been covered by Part D
d. It shouldn't have been
covered by Part B
06/01/2015
0%
0%
a.
b.
Medicare Drug Coverage Under Part A, Part B, and Part D
0%
c.
0%
d.
23
Case Scenario—3
Marian is 67 and has type 1 diabetes, congestive
heart failure, and chronic pain.
She takes all of her medications orally except for
her insulin which she self-injects.
Marian has Original Medicare and Part D.
06/01/2015
Medicare Drug Coverage Under Part A, Part B, and Part D
24
Check Your Knowledge—Question 7
Which part of Medicare
should cover Marian’s selfinjected insulin?
a.
b.
c.
d.
Part A
Part B
Part D
Her Medigap policy
0%
06/01/2015
0%
a.
b.
Medicare Drug Coverage Under Part A, Part B, and Part D
0%
c.
0%
d.
25
Case Scenario—4
Bob is 82 and has Autoimmune Hepatitis.
He was recently prescribed immunosuppressant
prednisone for this condition.
He has Original Medicare and Part D.
06/01/2015
Medicare Drug Coverage Under Part A, Part B, and Part D
26
Check Your Knowledge—Question 8
Which part of Medicare
should cover Bob’s selfinjected immunosuppressant
prednisone?
a.
b.
c.
d.
Part A
Part B
Part D
His Medigap policy
06/01/2015
0%
0%
a.
b.
Medicare Drug Coverage Under Part A, Part B, and Part D
0%
c.
0%
d.
27
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