Under Medicare rules, certain drugs administered in a physician's office or clinic, such as intramuscular (IM) injections, infusible drugs, or subcutaneous (SQ) injections not typically self-administered, are likely covered under a member's Independence Blue Cross (IBX) medical benefit, not their pharmacy benefit (Part D).
When your patients (our members) utilize their medical benefit for office-administered drugs, it's crucial to identify what is covered by their plan and any applicable guidelines for those medications. Our medical benefit aims to ensure members have safe and affordable access to covered medications.
Part B coverage details
The following information on Part B coverage of these drugs can be found within the IBX medical policies by searching for the name of the drug under Medicare Advantage:
- Examples: Some examples of these drugs include Prolia® and its biosimilars, and Botox®.
- Submission of requests: Requests for these drugs under the medical benefit can be submitted via the Provider Engagement, Analytics & Reporting (PEAR) portal using the Authorization Submission transaction in Practice Management or by calling 1-800-ASK-BLUE (1-800-275-2583).
The table below outlines examples of drugs typically administered in a physician's office or clinical setting that are not self-administered, along with the circumstances under which they may be covered under Medicare Part B.
Products
generally administered in a physician’s office or clinic (non-self-injectables)
(e.g. intramuscular injections, infusible drugs, or subcutaneous injections not
usually self-administered)
| Part
B coverage: If
medically necessary and supplied by any of the following: Physician, health
center/clinic, hospital, critical access hospital outpatient department,
ambulance, end-stage renal disease facilities, comprehensive outpatient
rehabilitation facility, hospital outpatient department, hospital outpatient
prospective payment system
|
Optum's role in processing requests
If a request is submitted to Optum, which reviews for Part D coverage, Optum will process the request. However, Medicare rules prohibit Part D coverage for drugs eligible under the medical benefit. If the drug is eligible for medical benefit coverage, Optum will issue a Part D coverage denial letter explaining the Incident-to-Provision requirements.
For more information about what drugs are covered under Part B, please refer to the IBX medical policies or call 1-800-ASK-BLUE (1-800-275-2583).
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