Medicare Part D

Members eligible for Medicare Parts A and B (dual eligibles) must enroll in a Medicare Part D plan for prescription drug coverage. Any individual seeking assistance in enrolling in a Medicare Part D PDP should call the Senior LinkAge Line^® at 1-800-333-2433 (toll free).

PrimeWest Health will not provide prescription drug coverage for dual eligibles who fail to or refuse to enroll in a Medicare Part D prescription plan. PrimeWest Health members who provide proof and use credible insurance to opt out of Medicare Part D will not be eligible for Low-Income Subsidy (LIS).

Self-administered medications during hospital observation stays should be billed to Part D. Hospitals may bill MedImpact on a 1500 form to the following address:

MedImpact Healthcare Systems, Inc.
10181 Scripps Gateway Ct
San Diego, CA 92131

Include the following information:

1. Member identification (ID) number
2. Member name
3. Date of birth (DOB)
4. Pharmacy NCPDP or NPI
5. Individual prescriber NPI
6. Rx number (if applicable)
7. NDC
8. Drug name
9. Fill date
10. Quantity
11. Day supply
12. Balance due amount

If the member is a dual eligible but the Medicare Part D plan cannot be verified, contact PrimeWest Health at 1‑866-431-0802 (toll free).

Medicare Part D Excluded Drug Categories

PrimeWest Health will cover certain classes of drugs for dual eligibles if excluded by law from the Medicare Part D program and if the drug or product is on the approved formulary list. Medicare Part D excludable drug categories include the following:

• Agents used for anorexia, weight loss, or weight gain (even if used for a non-cosmetic purpose [i.e., morbid obesity])
• Agents used to promote fertility
• Agents used for cosmetic purposes or hair growth
• Agents used for symptomatic relief of cough and colds
• Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
• Nonprescription drugs
• Agents used for the treatment of sexual or erectile dysfunction

Contact the individual Part D prescription plan with questions about denials, drugs not covered, and authorization requirements. PrimeWest Health will not cover a Part D eligible drug solely because it is “non-formulary” for a particular Part D plan.

Medicare Part D copay amounts are the member’s responsibility; do not bill PrimeWest Health.

Home Infusion Therapy (HIT)

HIT-related services are covered when provided by a PrimeWest Health-enrolled HIT pharmacy using the appropriate HIT per diem HCPCS codes or the specific codes used by Medicare or a TPL.

Home Infusion Pharmacy

Home infusion pharmacy refers to an established place, whether or not in conjunction with a hospital pharmacy, LTC pharmacy, or community/retail pharmacy that prepares, compounds, and dispenses parenteral or enteral drugs or medicines for the use of non-hospitalized patients and provides related pharmaceutical care services.

Eligible Providers

An HIT provider must meet the following requirements:

1. Has or is applying for a designated parenteral-enteral/home health care license category with the Minnesota Board of Pharmacy. If located outside of Minnesota, has Home Infusion Pharmacy designation with the state in which it is located, if the state makes such designations.
2. Has the ability to provide a full range of services, including but not limited to:
   1. Providing standards for preparation, labeling, and distribution of sterile products by licensed parenteral-enteral/home care pharmacies
   2. Having a policy and procedure manual addressing sterile preparation of products, clinical services, drug disposal, drug dispensing, labeling, quality assurance, etc.
   3. Meeting physical space and equipment requirements
   4. Having 24-hour staffing (pharmacist on call)
   5. Shipping
   6. Handling of cytotoxic agents
   7. Having a process for systematic drug use review
   8. Monitoring patients
   9. Having the ability to provide administrative and professional pharmacy services, care coordination, and all necessary supplies and equipment as defined by applicable home infusion HCPCS codes

Eligible Members

MHCP and Medicare members are eligible.

Members eligible for both MHCP and Medicare must receive most of their medication through Medicare Part D. MHCP will only cover drugs excluded by law from Medicare Part D coverage. Drugs eligible for Medicare Part B coverage must be submitted to the Medicare Part B carrier.

Covered Services

Per diem codes: S5497 – S5523, S9061, S9325 – S9331, S9336 – S9379, S9490 – S9504, S9537 – S9590

Reimbursement includes:

1. Initial patient assessment
2. Professional pharmacy services
3. Infusion therapy related equipment and supplies
4. Teaching
5. Coordination of care
6. Delivery and removal of equipment and supplies

Nursing Visits (99601 and 99602)

Home infusion and specialty drug administration must be performed by a skilled infusion nurse with specialized education and training in the alternate-site administration of drugs and biologics through infusion.

Nursing services may be billed by the following:

1. Home infusion pharmacy that has employed a home infusion nurse for HIT nursing services
2. Medicare-certified home health agency

Billing

Once the pharmacy is identified as a HIT pharmacy, use the 837P (Professional) transaction to submit claims for HIT services.

1. Enter the applicable HIT HCPCS codes (per diem S codes) that define the infusion, medical supplies, and the pharmacy professional service.
2. On a separate line, enter the appropriate HCPCS codes for the drugs, and report the NDC information for each drug in the LIN and CTP segments on a batch claim or in the Drug Pricing section on the Services tab in MN–ITS.
3. Use the appropriate modifiers (effective August 1, 2015, using SH and SJ modifiers will reduce line item payable to 50 percent of the current allowable charge):
   1. SH – 2nd Therapy – Second concurrently administered infusion therapy
   2. SJ – 3rd Therapy – Third or more concurrently administered infusion therapy

Refer to the Minnesota Uniform Companion Guide or the MN–ITS 837P User Guide for billing instructions.

Total Parenteral Nutrition (TPN) Billing

Lipids are currently covered under B4185 and other TPN compound drugs billable under B5000 – B5200. NDC and NDC quantities are required when billing.

The following standard products are included in the per diem (S9364 – S968):

1. Non-specialty amino acids (e.g., Aminosyn, FreAmine, Travasol)
2. Concentrated dextrose (e.g., D10, D20, D50, D60, D70)
3. Sterile water
4. Electrolytes (e.g., CaCl2, KCl, KPO4, MgSO4, NaAc, NaCl, NaPO4)
5. Standard multi-trace element solutions (e.g., MTE4, MVE5, MVE7)
6. Standard multivitamin solutions (e.g., MVI-12 or MVI-13)

The following items are not in the TPN per diem and are to be coded, billed, and reimbursed separately:

1. Specialty amino acids for renal failure (e.g., Aminess, Aminosyn-RF, NephroAmine, RenAmin)
2. Specialty amino acids for hepatic failure (e.g., HepatAmine)
3. Specialty amino acids for high-stress conditions (e.g., Aminosyn-HBC, BrachAmin, FreAmine HBC, Premasol, TrophAmine)
4. Specialty amino acids with concentrations of 15% and above when medically necessary for fluid-restricted patients (e.g., aminosyn 15%, Clinisol 15%, Novamine 15%, Prosol 20%)
5. Lipids (e.g., Intralipid, Liposyn)
6. Added trace elements not from a standard multi-trace element solution (e.g., chromium, copper, iodine, manganese, selenium, zinc)
7. Added vitamins not from a standard multivitamin solution (e.g., folic acid, vitamin C, vitamin K)
8. Products serving non-nutritional purposes (e.g., heparin, insulin, iron dextran, Pepcid, Sandostatin, Zotran)

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Updated_12/12/2024