B12 injections

fishfortwo

Expert
96
I have a client in her IEP, 65 this month. She has to have a monthly injection that is administered by the nurse in her doctors office. We have gone over the MAPD vs MS extensively and she wants the MAPD $0 HMO so please no debate on that. It shows as an OTC and not covered under Medicare.
Her employer plan covers it and she only pays a small co pay. She has Pernicious Anemia and has to have these shots. We checked the codes the provider uses the first is 96372 listed as therapeutic, prophylactic, or diagnostic injection. The second code is J 3420-vitamin B12 1000 MCG.
I cannot get a clear answer from the plan we are considering and was hoping one of you Gurus had dealt with this before and could let me know if this will be covered as an office visit, infusion, self pay and get reimbursed etc. I do not want to expose her to high cost obviously. Thanks in advance.
 
I had a similar case with a client who gets infusions. I forget what the drug is, but it is not in the Medicare formulary, Part B or D. The general rule is “if Medicare covers it, we cover it”. If someone is taking something not in a plan’s formulary when they go on the plan, the plan must provide it while the member and her Doc look for a formulary drug that works. Read the boilerplate in the first few pages of a Part D brochure, just FYI. Part B should apply here
 
Thank you both for the replies, they have been very helpful. The link provided by Northeast Agent leads me to believe this should be covered because of her condition but probably at 20% under part B with an MAPD. I would like to know the cost exactly for her benefit.I have emailed the Regional Manager of the carrier with the specifics and I am awaiting a reply. I did try as suggested numerous times with the carrier to talk with someone in claims and benefits. After going through the loop several times I was told they can only do that for an existing member not a prospective one. We have until the end of the month to pull the trigger. Again thanks for the advice.
 
Fishfortwo, depending on the cost of the shot, a Med Supp may be a better choice if it falls under Part B. After she pays the Part B yearly deductible, she'll be done with it. But it all depends on the MOOP for MAPDs in your area as well. They sound great until you start paying out of pocket.
 
Preaching to the choir. I have been over and over that with her. Her thoughts are if it is too much she can exercise the trial right. It appears at this point the cost of the B12 range on the low end $10 to $40 so it should be 20% of that. The PCP visit is a $0 co pay. The moop is $4500 and going down significantly for 2019.
 
Yes exactly, and that was my knee jerk reaction. I have several of my clients on those as well as my mother. I have just never had the issue of Pernicious Anemia and B12 come up before. I just wanted to dot my i's and cross my t's. Thanks for the input.
 
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