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Revised: 01-02-2013

Medicare Coverage

This section provides a brief overview of drug coverage and billing for Medicare and Minnesota Health Care Programs (MHCP). Always verify coverage and criteria with CMS or the individual Medicare Part D plan before dispensing or billing drugs.

Medicare Part B

Commonly covered drugs

  • • Drugs used for immunosuppressive therapy
  • • Oral chemotherapy drugs
  • • Oral anti-emetics used for cancer patients
  • • Drugs used for inhalation and administered by nebulization
  • • Blood clotting factors
  • • Influenza vaccines
  • MHCP will pay Medicare Part B co-insurance as directed by Medicare Part B for eligible recipients.

    Use your POS software to bill for self-administered Medicare Part B drugs using the appropriate National Drug Code (NDC). Do not bill MHCP the same day you bill Medicare. If all of your MHCP and Medicare provider information on file is correct Medicare will cross the claim over to MHCP with payment details.

    If Medicare does not cross the claim over to MHCP within six weeks, bill MHCP using MN–ITS 837P Use the appropriate HCPCS (J)code and modifiers. Report the corresponding NDC in the appropriate fields on the claim and include Medicare determination and payment details. Refer to the MN–ITS Professional 837P User Guide for complete billing instructions

    Medicare Part D

    Effective January 1, 2006, MHCP recipients eligible for Medicare Parts A and B (dual eligibles) must enroll in a Medicare Part D plan for prescription drug coverage. Any individual seeking assistance in enrolling in a Medicare Part D prescription drug plan should call the Linkage Line at 1-800-333-2433.

    For individuals whose Medicare Part D entitlement determination is made retroactively, Part D eligibility will begin with the month the individual receives the notice of entitlement determination.

    MHCP will not provide prescription drug coverage for dual eligibles that fail to or refuse to enroll in a Medicare Part D prescription plan. MHCP recipients who provide proof and use credible insurance to opt out of Medicare Part D will not be eligible for Low Income subsidy.

    If the recipient is a dual eligible but the Medicare Part D plan cannot be verified, contact Humana at 1-800-865-8715.

    Medicare Part D Excluded Drug Categories
    MHCP will cover certain classes of drugs for dual eligibles if excluded by law from the Medicare Part D program and if the drug or product is on the MHCP approved formulary list. Medicare Part D excludable drug categories include:

  • • Agents used for symptomatic relief of cough and colds
  • • Barbiturates when used for the treatment of conditions other than epilepsy, cancer, or chronic mental health conditions
  • • Over the Counter (OTC) items including smoking cessation products
  • • Prescription vitamins and mineral products
  • Contact the individual Part D prescription plan with questions about denials, drugs not covered and authorization requirements. MHCP will not cover a Part D eligible drug solely because it is “non-formulary” for a particular Part D plan.

    Medicare Part D copay amounts are the recipient’s responsibility; do not bill MHCP, except for qualified recipients of MHCP Program HH.

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