Pharmacy Question for the Week of June 24, 2019

Pharmacy Compliance Question of the Week

Question:

How does the term “usually” apply to the Medicare drug payment?

Answer:

For the purposes of applying this exclusion, the term “usually” means more than 50 percent of the time for all Medicare beneficiaries who use the drug. Therefore, if a drug is self-administered by more than 50 percent of Medicare beneficiaries, the drug is excluded from coverage and the A/B Medicare Administrative Contractor (MAC), or home health and hospice (HHH) MAC may not make any Medicare payment for it. In arriving at a single determination as to whether a drug is usually self-administered, A/B MACs and (HHH) should make a separate determination for each indication for a drug as to whether it is usually self-administered.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.