Download FreedomBlue PPO and PFFS Part B Copays

FREEDOMBLUE PPO AND PFFS MODIFY COPAYMENT GUIDELINES
FOR CERTAIN MEDICARE PART B MEDICATIONS
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Effective immediately, Highmark is modifying the copayment guidelines it applies to certain
Medicare Part B medications administered to Medicare Advantage members – those with coverage
under FreedomBlueSM PPO and FreedomBlue PFFS (Private Fee for Service). The copayment for
these medications will now be administered as $2 per drug, per date of service. (Please note that
members with retiree coverage through an employer group may have a different cost-sharing
structure, as discussed below.)
Highmark Medicare Advantage members are responsible for a copayment of $2 per Part B drug, per
date of service, when such drugs are administered to them by a health care professional. This
copayment applies specifically to members with individual coverage under Highmark’s Medicare
Advantage products. Please note that members whose FreedomBlue PPO or FreedomBlue PFFS
coverage is sponsored by an employer group may have a different cost-sharing structure.
When in doubt, facilities should contact the appropriate Provider Service unit, as directed
later in this bulletin.
Within the next several weeks, Highmark will begin reprocessing claims already submitted for drugs
in these categories provided to Highmark Medicare Advantage members since January 1, 2008. Any
applicable adjustments will be issued to providers. Providers who have already collected
copayments from members for dates of service on or after January 1, 2008, should make
arrangements to reimburse members for copayments that exceed $2 per drug per date of service, as
reflected in the remittance advice for the reprocessed claim, if appropriate.
Guidelines for Collection of Part B Copayment for Highmark Medicare Advantage Members
Providers are reminded that copayments are due at the time of service. The Part B copayment for
Medicare Advantage members is $2 per drug in the circumstances described below. When members
are receiving Part B drug(s) as part of a multi-session course of treatment, the $2 copayment should
be collected for each Medicare Part B drug administered during the session. For example, if a
patient receives three Part B drugs during a treatment session, providers should collect a total of $6
copayments ($2 for each drug administered). As always, if the allowable amount of the Medicare
Part B drug is less than the copayment amount, the member is only responsible for the lesser
amount.
Drugs to Which $2 Copayment Applies
The $2 per drug per date of service copayment applies health care professional-administered drugs in
the following categories:

Drugs that include substances naturally present in the body, including blood clotting factors
and insulin

Clotting factors if the patient has hemophilia

Immunosuppressive drugs if the patient has had an organ transplant covered by Medicare
(These drugs may be covered under Part D when used for any other clinical indication. In
those situations, the member’s Part D copayment may apply.)

Injectable osteoporosis drugs, if the patient is homebound and has a bone fracture that a
physician certifies was related to post-menopausal osteoporosis

Chemotherapy
Copayments for Outpatient Dialysis Services
Highmark will assess a copayment of $25 per drug, per month, for certain Part B drugs
administered during outpatient facility dialysis, including outpatient departments of acute-care
hospitals and free-standing dialysis facilities. This category of drugs includes heparin, heparin
antidote (when medically necessary), topical anesthetics, erythropoietin (Epogen) or Epoetin Alfa
and Darboetin Alfa. As a reminder, patients who receive dialysis as a component of inpatient care
are not subject to the Part B drug copayment but may have cost-sharing related to the inpatient
confinement.
Drugs Used In Conjunction With Anesthesia and Radiology Services
Highmark has made every effort to exclude from the copayment requirement drugs that are used in
conjunction with anesthesia and radiology services. However, since some drugs have multiple uses,
there is no guarantee that all such drugs have in fact been excluded from the copayment requirement.
Medications Furnished as Part of a Service Performed by a Health Care Professional
Medicare Part B covers a limited set of drugs -- injectable and infusible drugs that are not usually
self-administered and that are furnished and administered as part of a service performed by a health
care professional. Medicare Part B also covers a limited number of other types of drugs. These are
shown in the attached chart titled “Medicare Part B Drugs Quick Reference Guide,” which providers
may wish to keep at hand for future reference.
Certain categories of Medicare Part D drugs have been excluded from the copayment requirement,
including those classified as Medicare Part B Exclusion Drugs. In addition to these drugs, which the
Medicare Program has specifically excluded from coverage for Medicare Advantage and Part D
members, the following are also excluded from the Part B copayment:




Vaccines and Toxoids (CPT 90371 through 90747)
Miscellaneous Drugs and Solutions (HCPCS J7030 through J7130; J7308 through J7349)
Miscellaneous Pathology and Laboratory (HCPCS P9041 through P9048)
Contrast Materials (HCPCS A9576 through A9579; Q9953-Q9954; Q9956 through Q9958;
and Q9960 through Q9967)
Use NaviNet to Verify Copayment for Medicare Advantage Members
When verifying member eligibility, providers should also confirm the appropriate copayment amount
for the service. Highmark has now added functionality to Highmark Blue Shield sponsored Navinet
that allows providers to confirm copayment amounts for Medicare Advantage members with
individual coverage. Providers can simply click on Eligibility & Benefits and select the Other
Services link, to confirm the member’s Part B drug copayment amount. As always, if the allowed
amount of the Medicare Part B drug is less than the copayment amount, the member will be
responsible for the lesser amount. Please remember that some members who are covered by
group-sponsored retiree plans may have different copayment amounts. Highmark is also working to
add the ability to confirm the copayment amount for members with group-sponsored coverage via
Highmark Blue Shield sponsored Navinet. Providers will be notified when this functionality has
been added.
Medicare Part B Drug Reference Resources for Provider Use
For providers’ convenience, a complete list of Medicare Part B drugs, codes, dosing and copayment
information for 2008 is attached to this bulletin. The current list is also available on the Highmark
Blue Shield sponsored NaviNet Facility Provider Resource Center. To view the list, hover on
Administrative Reference Materials and select 2008 Medicare Part-B Drug List from the drop-down
menu.
If you have questions regarding this bulletin should be directed to the appropriate Provider Service
unit, based on the product under which the Medicare Advantage member has coverage:
For members with coverage under...
FreedomBlue PPO
FreedomBlue PFFS
Contact Provider Service at…
1-866-803-3708, option 3, or 1-866-588-6967
1-866-675-8635
FreedomBlue is a service mark of the Blue Cross and Blue Shield Association
NaviNet is a registered service mark of NaviMedix, Inc. NaviMedix, Inc. is an independent company
that does not provide Highmark products or services. NaviMedix, Inc. is solely responsible for the
products and services that they provide and that are referenced in this bulletin.