CMS Pub. 100-16, ch. mc86c17f, § 20.3

(Rev. 77, Issued: 10-28-05, Effective Date: 10-28-05)

(Chapter 4, §20.9 of the Medicare Managed Care Manual) For this subsection, the term

“drug” means “drug or biological.” As indicated in §10.1, a Medicare cost plan must

provide its enrollees with coverage of all drugs covered under original Medicare Part B.

Part B Medicare covers drugs in a limited number of cases including the following:

• Drugs that the Medicare cost plan enrollee takes while using durable medical

equipment (such as nebulizers) that were authorized by the enrollee’s

Medicare cost plan;

• Clotting factors if the enrollee is diagnosed with specific blood-clotting

disorders;

• Immunosuppressive drugs, if the enrollee had an organ transplant that was

covered by Medicare;

• Injectable osteoporosis drugs, if the enrollee has a bone fracture that a doctor

certifies was related to post-menopausal osteoporosis, and cannot self-administer the drug;

• Antigens;

• Certain oral anti-cancer drugs and anti-nausea drugs; and

• Erythropoietin by injection if the member has end-stage renal disease and

needs this drug to treat anemia.

• Not Usually Self-Administered (NUSA) Drugs. If a drug is defined as: (a)

not usually self-administered (NUSA) by the carrier in the area covered by the

Medicare cost plan, and (b) the drug is delivered incident to a physician

service, then it is classified as a Medicare-covered drug under Part B. Some

Medicare cost plans contract with specialty pharmacies to supply NUSA

drugs to their providers, instead of having the provider purchase and bill the

plan. If the drugs are furnished incident to a physician's service and they are

covered in that setting by the carrier whose coverage decisions are followed

by the Medicare cost plan, they are still classified as Part B drugs --

regardless of the payment arrangements.

A Medicare cost plan cannot make their own determinations of what is a

Medicare-covered Part B drug; rather carriers make these determinations.

A NUSA drug obtained by an enrollee at a pharmacy is not covered under

Part B.