Medicare Coverage of Oral Cancer & Anti-Nausea Drugs
In deciding whether to go with a stand-alone Medicare Part D (prescription drug coverage) and, if so, which Part D plan to join, cancer patients have some special things to think about.
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 (chemo) 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 chemo drugs given by mouth and anti-nausea drugs given by mouth (these are often 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 are taken by mouth as part of chemo. 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 drug by mouth or the same drug as an IV, the oral drug is covered under Part B.
In contrast, oral cancer drugs that cannot be given by IV are covered under Part D.
Anti-nausea drugs taken by mouth
Anti-nausea drugs are often used as part of chemo. The rule for anti-nausea drugs taken by mouth is much the same. If your doctor has a choice between giving you an anti-nausea drug by mouth or through 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 through 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, the drug is covered under Part D, not 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 a Medicare beneficiary needs 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 annual 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 a Medicare Supplemental or Medigap insurance to cover their out-of-pocket costs under Part B.) Finding the best fit Medigap plan can be a challenge. So, the agents connected to this website can advise and assist by helping a Medicare beneficiary understand and acquire the best possible Medigap plan as well as a Part D plan.
Part D is different. After you pay a certain deductible for your drugs, you must pay a; pre-established copay, or a percentage of your drug costs for the rest of the year, or until you reach the coverage gap, also known as the donut hole. Again, this deductible and coverage gap amount is set each year by the federal government.
Because some cancer drugs are clearly covered under Part B, like those given through an IV in your doctor’s office, you might not be able to find all of your cancer treatment drugs on a Part D plan’s formulary. (The list of drugs that are covered under a plan is called a formulary. 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 or the agent connected to this website. 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 and 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 approved by the FDA. 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 in cancer care in the United States are off label. If you would like to learn more about this, please examine Off-label Drug Use.