Reclast, Prolia - Change in Part B Coverage?

[somarco]

Client contacted me about Prolia or Reclast injections. Her doc told her they were covered by Part B, but 800-MEDICARE said no.

A couple of searches, here, and here, seems to indicate the drugs are covered by B but only if you are on home health care.

Injectable osteoporosis drugs: Medicare helps pay for an injectable drug for women with osteoporosis who meet the criteria for the Medicare home health benefit and have a bone fracture that a doctor certifies was related to post-menopausal osteoporosis

Osteoporosis drugs for women
Women with Medicare are covered if they:

• Are eligible for Part B
• Meet the criteria for Medicare home health services
• Have a bone fracture that a doctor certifies is related to post-menopausal osteoporosis

I know Medicare is trying to reduce the number of drugs covered by Part B but this seems to be a recent change.

Are other in office administered drugs still covered by Part B or is this just a shift for osteo drugs which are now covered by Part D?

 

[Chazm]

I’ve had a client on Prolia for several years now but it’s covered through her part D.

 

[somarco]

That's a bummer.

Tier 4, $1,000+ drug with 30% - 50% copay, and no gap coverage.

 

[LostDollar]

There was a thread somewhere that talked about Mark's Marine Pharmacy shipping insulin.
That led me to check those drugs you listed, they both come up-still expensive, but maybe an option (And I may not appreciate what expensive really is with some of these drugs).

 

[Midlevel]

I have a lot of women taking Prolia shots twice a year and have always been covered 100% through Part B and Med Sup. My MA clients have always paid the 20% copay for injections. This would be a huge deal if they really change it to a Part D prescription. I'm sure most will just stop doing it because they already question if it is worth it but do it since it's free. They will go back to the cheap osteoporosis drugs that are now generic.

 

[kgmom219]

Client contacted me about Prolia or Reclast injections. Her doc told her they were covered by Part B, but 800-MEDICARE said no.

A couple of searches, here, and here, seems to indicate the drugs are covered by B but only if you are on home health care.

Injectable osteoporosis drugs: Medicare helps pay for an injectable drug for women with osteoporosis who meet the criteria for the Medicare home health benefit and have a bone fracture that a doctor certifies was related to post-menopausal osteoporosis

Osteoporosis drugs for women
Women with Medicare are covered if they:

• 
  
  
  • Are eligible for Part B
  • Meet the criteria for Medicare home health services
  • Have a bone fracture that a doctor certifies is related to post-menopausal osteoporosis

I know Medicare is trying to reduce the number of drugs covered by Part B but this seems to be a recent change.

Are other in office administered drugs still covered by Part B or is this just a shift for osteo drugs which are now covered by Part D?

I'm going with osteo drugs only, but only because there isn't anything else that looks different.

You left off this bullet point:
Are certified by a doctor as unable to learn to give themselves the drug by injection, and family members and/or caregivers are unable or unwilling to give you the drug by injection

Which I found interesting because the prescribing info (the FDA approved fine print) has this in it and it was updated on 5/2017:

Are certified by a doctor as unable to learn to give themselves the drug by injection, and family members and/or caregivers are unable or unwilling to give you the drug by injection

If all they are doing is shifting coverage from a docs office to Home Health, I'm fine with that. Its still a professional doing the injection and its significantly less expensive to pay for a Home Health visit than a doc visit.

 

[Chazm]

Hmm I may need to remember which client of mine takes prolia and see if she can get it under part b at her dr office. I just have a horrible memory.

 

[somarco]

You left off this bullet point:
Are certified by a doctor as unable to learn to give themselves the drug by injection, and family members and/or caregivers are unable or unwilling to give you the drug by injection

Yeah, but I provided the links.

Can't say if Prolia or Reclast were ever under Part D or not. If CMS recently added those drugs to PDP formularies then that might explain why they are making it difficult to get them covered under Part B.

If these drugs can now be self administered it makes sense to move them off B to D . . . which is precisely what Medicare wants. Shift the cost from Medicare to private insurance and beneficiaries.

Those receiving home health may already be using a nurse, so allowing payment under B for a nurse to administer makes sense.

But if you are on Medicare and not on home health, it seems you can no longer have it covered under B.

Not too long ago Fosamax was used primarily for osteoporosis. Then we got Actonel (Risendronate - generic), then Boniva and now Prolia and Reclast.

The latter two drugs appear to have been developed for those who have had bone loss associated with cancer treatment and/or have had bone cancer.

Earlier drugs possibly were not as effective in this specific situation.

It is still my contention that Medicare is forcing the move to Part D to save money.

 

[kgmom219]

Yeah, but I provided the links.

It is still my contention that Medicare is forcing the move to Part D to save money.

I wasn't questioning that you left it off. I was merely pointing out that it makes a difference.

The prescribing guidelines aren't "suggestions" from the manufacturer. The guidelines are part of the FDA approval process. Technically, if your doctor isn't following the guidelines, they are guilty of malpractice.

My point is that the 4th bullet point makes the difference.

"Prolia should be administered by a healthcare professional"

Osteoporosis at High Risk for Fracture Treatment | Prolia® (denosumab)

Medicare rules (and carriers) cannot override the FDA. And if it requires a professional, that makes it Part B.

If Medicare wants move it to Part D, they better call the FDA and get the guidelines updated.

 

[somarco]

OK, now I see.

But the wording re home health care seems to indicate the drug CAN be self administered.

In spite of your terse (and I am certain accurate warning) my guess is the folks at Medicare will do whatever they please and to hell with the FDA.

But back to your quote . . .

Prolia SHOULD be administered by a healthcare professional seems to be a suggestion, not a mandate. Otherwise they substitute MUST for SHOULD.

Picking nits . . .