New and Updated for 2007

For Plans, PBMs and Pharmaceutical Manufacturers

There are a host of ambiguities regarding which outpatient drugs are covered under Medicare Part B versus the new Medicare Part D prescription benefit.   New CMS rules for processing Part D prescription claims -- combined with multifaceted and complex  agency guidance on when, and in which situations, specific drugs should be covered under B versus D -- has created considerable confusion for MA-PD plans, PDPs, providers, and beneficiaries.

As a result, many Medicare drug plan sponsors simply “guess” how to code and bill for drugs that fall in the gray zones – even though accurate coding and billing are critical.  Plans that incorrectly shift costs between Part B and Part D potentially risk losing thousands of reimbursement dollars per drug claim.  Additionally, patterns of incorrect or inappropriate billing could inadvertently reduce the amount of risk-adjustment payments plans receive from CMS, result in inaccurate beneficiary cost-sharing, and/or potentially expose plans to CMS audits and allegations of Medicare fraud, waste, and abuse.

GHG’s B vs. D Navigator helps plans navigate through the complex maze of Part B versus Part D billing, coverage and coding requirements. The Navigator will help you bill and process Medicare prescription drug claims more efficiently and more accurately than you could on your own.  You’ll get specifics on which circumstances trigger coverage under Part D versus Part B, along with appropriate coding information for the drug types that are the most problematic to decipher, including:

• Immunosuppressive Agents
• Hemophilia Clotting Factors
• Oral Anti-Cancer Drugs
• Oral Anti-Emetic Drugs Used with Intravenous Chemotherapy
• Anti-Emetic Drugs Used with Covered Oral Anti-Cancer Drugs
• Aprepitant and Dexamethasone
• Pneumococcal, Hepatitis B, Influenza, and Miscellaneous Vaccines
• Antigens
• Erythropoietin
• Parenteral Nutrition
• Intravenous Immune Globulin
• Infusion Drugs
• Injectable Drugs
• Inhalation Drugs and Solutions Used with Nebulizers

Because GHG’s comprehensive document brings all together in one place, for the first time, CMS agency and critical Medicare carrier guidance in this area, the tool is equally useful for pharmaceutical manufacturers and PBMs looking for clarity on these very issues.