Part B Guideline for Immunos

[Guest guest]

Does anyone know where I can find a guideline stating Part B is to always cover immunos for a Medicare approved kidney transplant? I have a pharmacy telling me that they switch all patients from Part B to Part D after one year. Not sure

where this logic is coming from?

Sara Danner

| Transplant Financial Coordinator | Memorial Medical Center | Springfield, IL

Phone: | Fax: | E-mail:

danner.sara@...

This message (including any attachments) contains confidential information intended for a specific individual and purpose, and is protected by law. If you are not the intended recipient, you should delete this message.

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[Guest guest]

…well you just never know what kind of crazy things people are going to tell you…

Medicare Claims Processing Manual

Chapter 8 - Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims

120.1 - Payment for Immunosuppressive Drugs Furnished to Transplant Patients

(Rev. 1, 10-01-03)

PRM-1-2711.5, B3-4471, AB-01-10

A. General

Effective January 1, 1987, Medicare pays for FDA approved self-administered immunosuppressive drugs. Generally, under this benefit, payment is made for self-administered immunosuppressive drugs that are specifically labeled and approved

for marketing as such by the FDA, as well as those prescription drugs, such as prednisone, that are used in conjunction with immunosuppressive drugs as part of a therapeutic regimen reflected in FDA approved labeling for immunosuppressive drugs. This benefit

is subject to the Part B deductible and coinsurance provision.

There is no time limitation on the coverage of these drugs; however, if a beneficiary loses Medicare coverage as a result of the transplant, the drugs are no longer covered. When the beneficiary reaches the age of 65 and becomes entitled, that person

can have the drugs covered again. The hospital pharmacy must ask the physician to furnish the patient with a non-refillable 30-day prescription for the immunosuppressive drugs. This is because the dosage of these drugs frequently diminishes over a period of

time, and it is not uncommon for the physician to change the prescription from one drug to another because of the patient’s needs. Also, these drugs are expensive, and the coinsurance liability on unused drugs could be a financial burden to the beneficiary.

Unless there are special circumstances, the FI and carrier do not consider a supply of drugs in excess of 30 days to be reasonable and necessary and limits payment accordingly.

From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ]

On Behalf Of Danner, Sara

Sent: Tuesday, August 21, 2012 4:17 PM

To: TxFinancialCoordinators

Subject: Part B Guideline for Immunos

Does anyone know where I can find a guideline stating Part B is to always cover immunos for a Medicare approved kidney transplant? I have a pharmacy telling me that they switch all patients from Part B to Part D after one year.

Not sure where this logic is coming from?

Sara Danner

| Transplant Financial Coordinator | Memorial Medical Center | Springfield, IL

Phone: | Fax: | E-mail:

danner.sara@...

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[Guest guest]

As long as the patient had Medicare A at

the time of his/her transplant if the pharmacy tried to put it through D then a

PA would be requested and the D plan would ask if the patient had Medicare A at

the time of the transplant and if the answer is yes then the D plan would deny

coverage.

Daryl Battin

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Ms. Daryl

Battin, MSW/LICSW

Financial

Coordinator/Social Worker

Department of

Transplantation

Lahey Clinic, 41 Mall Road, Burlington

MA 01805

Ph:

Page:

FAX:

From: TxFinancialCoordinators [mailto:TxFinancialCoordinators ] On Behalf Of Danner, Sara

Sent: Tuesday, August 21, 2012 4:17

PM

To: TxFinancialCoordinators

Subject:

Part B Guideline for Immunos

Does anyone know

where I can find a guideline stating Part B is to always cover immunos for a

Medicare approved kidney transplant? I have a pharmacy telling me that

they switch all patients from Part B to Part D after one year. Not sure

where this logic is coming from?

Sara Danner | Transplant Financial Coordinator | Memorial

Medical Center

| Springfield, IL

Phone: | Fax: | E-mail: danner.sara@...

This message (including any attachments)

contains confidential information intended for a specific individual and

purpose, and is protected by law. If you are not the intended recipient, you

should delete this message. Any disclosure, copying, or distribution of this

message, or the taking of any action based on it, is strictly prohibited.

See our web page at http://www.lahey.org for a full directory of Lahey sites, staff, services and career opportunities.

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