Accessing Pharmaceuticals through Medicare: Part B versus Part D

One of the areas of uncertainty posed by the Medicare Part D prescription benefit program is how to acquire a medication that is covered under both the Part D and Part B. Part B drug coverage is for drugs billed by a physician for medications ordered and dispensed or ordered and administered by a physician. Part D drug coverage is for medications dispensed per prescription and usually is self-administered by the patient. When a drug is covered by both Part D and Part B, the final method of payment and access to the necessary pharmaceutical agent is based on situational factors, including the patient's residence and where the patient initially received the care or procedure necessitating the use of the medication. The process becomes even more complicated when considering Medicaid dual eligible patients. Two examples of the application of the situational rules are discussed in this paper to illustrate the issues propelling the navigation between the different programs. One is a new antiemetic drug which is administered as three daily doses, one prior to chemotherapy, and one each of the following two days at home for the prevention of chemotherapy induced nausea and vomiting. The second example discussed is a new prophylactic vaccine for the human papilloma virus which is indicated by the FDA for only females aged 9-26 years of age for the prevention of cervical cancer. Depending on the patient's circumstances, Part B or D or a combination provide access and continuity of care.