In deciding whether to
go with Medicare Part D and, if so, which Part D plan to join, cancer
patients have some special things to think about.
As noted before,
most prescription drugs are covered through the Medicare Part D
benefit. This includes drugs used to treat high blood pressure, high
cholesterol, arthritis, depression, and other health conditions. These
medicines can be pills or liquids taken by mouth, suppositories,
inhaled drugs (like those used to treat asthma), and drugs that are
injected by patients (like insulin for people with diabetes). A general
rule is that Part D covers medicines prescribed by your doctor that
you get at your local pharmacy.
Many cancer drugs will still be covered under Part B, not Part D
Medicare
Part B covers doctor visits and outpatient hospital services. Part B
also covers the drugs that are infused (given in a vein through an IV)
or injected (given as a shot) in a doctor’s office or treatment center.
Many chemotherapy drugs and the anti-nausea drugs used along with
chemo are given by IV infusion in a doctor’s office or clinic. This
means they are still covered under Part B.
The difference in
coverage for cancer drugs under Medicare Part B and Medicare Part D is
blurred when it comes to chemotherapy drugs given by mouth and
anti-nausea drugs given by mouth (these may be called oral drugs). Some of these drugs are covered under Part B, but others are covered under Part D.
Cancer treatment drugs taken by mouth
Some
cancer drugs taken by mouth as part of chemotherapy are covered under
Part B. For the most part, these drugs are covered under Part B if they
are used instead of the same drug that could be given through an IV in
your doctor’s office. In other words, if your doctor has a choice
between giving you an oral drug or the same drug as an IV, the oral
drug is covered under Part B.
In comparison, oral cancer drugs that cannot be given as an IV are covered under Part D, not Part B.
Anti-nausea drugs taken by mouth
Anti-nausea
drugs are often used as part of chemotherapy. The rule for anti-nausea
drugs taken by mouth is much the same. If your doctor has a choice
between giving you an oral anti-nausea drug or the same drug as an IV
and the drug is given within 48 hours of chemo, then the oral drug is
covered under Part B.
Oral anti-nausea drugs that cannot be given
as an IV are covered under Part D, not Part B. (If an anti-nausea drug
is prescribed for a patient who is not known to have cancer, then the
drug is covered under Part D rather than Part B.)
Sorting out Medicare Part B and Part D
Many
people find the rules for the difference between Medicare coverage
under Part B and Part D hard to understand. For people with cancer, the
rules can be even more confusing because some cancer drugs are already
covered under Part B.
As a general rule, drugs that patients can
inject on their own without help from a doctor or nurse, or that are
not taken as part of chemo are covered under Part D.
If you have
more questions, your doctor and his and her office staff should be able
to help you sort through the coverage rules. They can help you figure
out whether a drug is covered under Medicare Part B or Medicare Part D.
Why do I need to know if a drug is covered under Part B or Part D?
It’s
important to understand the difference between drug coverage under Part
B and coverage under Part D because your out-of-pocket costs will vary
depending on which part covers each drug.
For services covered
under Medicare Part B, patients must first pay the yearly deductible
that is set by Medicare each year. After that, Medicare pays 80% of all
costs. This means that under Part B, patients must pay 20% of the
drug’s cost no matter how high their total medical bills run. (Many
people with Medicare have supplemental or Medigap insurance — or other ways — to cover their out-of-pocket costs under Part B.)
Part
D is different. After you pay a certain deductible for your drugs, you
must pay 5% of all ongoing drug costs for the rest of the year unless
you reach the donut hole. Again, this deductible amount is set each
year. In 2012, the deductible amount for Part D is set at $320. For
donut hole information and the 2012 example, see “What is the coverage
gap, and what do I pay?” in the section called “What is the Medicare
Part D drug benefit?”
You should also know that some cancer drugs
are clearly covered under Part B, like those given through an IV in
your doctor’s office. Because of this, you might not be able to find
all of the drugs that are part of your cancer treatment on a Part D
plan’s formulary. (The list of drugs that are covered under a plan is
called a formulary; see the section “Formularies and drug
coverage” for more on this.) If you are deciding whether to enroll in a
drug plan and you don’t see a drug you need on a plan’s formulary, call
the plan. You’ll want to ask if they might cover the drug and how you
can go about getting it covered.
What about off-label drugs and Part D?
What is off-label drug use?
When
the Food and Drug Administration (FDA) approves a new drug, it means
the federal government has found the drug to be safe and effective for a
certain disease or condition. The label information printed in the
official prescribing information and in the package insert explains the
use for which the FDA has approved the drug. It describes the approved
dose and way the drug should be given (as a pill, injection, infusion,
etc.). But in some cases, doctors — based on their knowledge and new
information — may prescribe a drug for a use that is not listed
in the approved labeling. The use of a drug for a disease the FDA did
not approve it for, or in a dose or by a route that is not listed on
the label, is called “off-label” use of the drug.
Off-label drug
use is legal in the United States and in many other countries. But
drugs used off label are only covered under Part D if the use is cited
in one of the reference standards for prescription drugs (called a compendium)
named in the Medicare law. Part B may cover off-label use of cancer
drugs, but Part D drug plans cannot cover any use not listed in one of
the approved reference standards.
Why is this important to a cancer patient?
The
National Comprehensive Cancer Network estimates that about half of all
uses of drugs and biologics in cancer care in the United States are off
label. If you would like to learn more about this, please see our
document called Off-label Drug Use.
Last Medical Review: 10/14/2011
Last Revised: 10/14/2011
