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Prescription Drug Part B
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Part B Prescription Drugs

Medicare Part B (Medical Insurance) covers a limited number of outpatient prescription drugs under limited conditions. Usually, drugs covered under Part B are drugs you would not usually give to yourself, like those that you get by injection or infusion in a doctor's office or ambulatory setting.

Some drugs covered by Part B have certain utilization criteria, including step therapy (ST) and preauthorization (PA). This with the purpose of promoting and facilitating members’ access to cost-effective therapies that treat certain chronic diseases.

Prior Authorization

MCS Classicare requires prior authorization for certain drugs. This means that members will need to get approval from MCS Classicare before filling the prescriptions. If members do not get approval, MCS Classicare may not cover the drug.

MCS Classicare will use national coverage determinations (NCDs), local coverage determinations (LCDs) and the general conditions of coverage and benefits included in our region's Traditional Medicare laws for the evaluation of Part B drugs with a pre-authorization requirement. This includes criteria for determining whether an item or service is an available benefit under Traditional Medicare.

When coverage criteria are not established in applicable Medicare statutes, regulations, NCDs or LCDs, MCS Classicare will create internal coverage criteria that will be based on Food and Drug Administration (FDA) approved indications and based on current evidence presented in clinical guidelines or clinical literature made available to the public.

Step Therapy

In some cases, MCS Classicare requires the member to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and B both treat your medical condition, MCS Classicare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, MCS Classicare will then cover Drug B.

Medicare outpatient drug coverage (Part B) for patients is described in the Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50 Drugs and Biologics. In addition, there may be the following policies established by Medicare the National Coverage Determination (NCD), Local Coverage Determinations (LCD) with which we are required to be in compliance when applicable to our region. Step therapy requirement will be required for the drugs listed below as long as the following requirements are met for the requested drug:

  • Meets the definition of a Part B drug under Medicare.
  • The patient is considered to have started new on the non-preferred product (defined as no use in the previous 365 days).
  • The proposed use of the requested product has been determined to be a medically accepted indication.
  • The proposed use of the preferred alternative agent has been determined to be a medically accepted indication.
  • The dose, frequency and duration of use cannot exceed the safety and efficacy data supporting the medically accepted indication.