Medicare Part B

Commonly Covered Drugs

• Drugs used for immunosuppressive therapy for a member who has received a Medicare-covered organ transplant
• Oral chemotherapy drugs provided they have the same active ingredients and are used for the same indications as chemotherapy drugs that would be covered if they were not self-administered and were administered as incident to a physician’s professional service
• Oral anti-emetics used for cancer patients when used as part of a chemotherapeutic regimen as a full therapeutic replacement for an IV anti-emetic drug within 48 hours of chemotherapy administration
• Drugs used for inhalation and administered by nebulization
• Hemophilia clotting factors for members competent to use such factors to control bleeding without medical supervision, and items related to the administration of such factors
• Influenza vaccines

PrimeWest Health will pay Medicare Part B co-insurance as directed by Medicare Part B for eligible members.

Use your POS software to bill for self-administered Medicare Part B drugs using the appropriate NDC. Do not bill PrimeWest Health the same day you bill Medicare. If all of your PrimeWest Health and Medicare provider information on file is correct, Medicare will cross the claim over to PrimeWest Health with payment details.

If Medicare does not cross the claim over to PrimeWest Health within six weeks, bill PrimeWest Health using the 837P claim format. Use the appropriate HCPCS J code and modifiers. Report the corresponding NDC in the appropriate fields on the claim and include Medicare determination and payment details.

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Updated_10/02/2023