Drug Lists
You are now leaving Health Net's website for Medicare.gov. While Health Net believes you may find value in reading the contents of this site, Health Net does not endorse, control or take responsibility for this organization, its views or the accuracy of the information contained on the destination server. To proceed to Medicare.gov, click 'Continue'. To stay on the Health Net website, click 'Cancel'. If you would prefer to speak to a Health Net representative about this issue, please click here to go to our Customer Service Center page. Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service, or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the Member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether, under the facts and circumstances of a particular case, the proposed procedure, drug, service, or supply is medically necessary. The conclusion that a procedure, drug, service, or supply is medically necessary does not constitute coverage. The Member's contract defines which procedure, drug, service, or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and curre Continue reading >>
Medicare Coverage To Treat Diabetes
Diabetes is a common medical condition in which the body either doesnt make enough insulin or doesnt respond properly to the insulin it makes. A healthy body uses insulin to process sugars, but when there isnt enough insulin in the body, too much sugar stays in your blood. If your blood sugar remains consistently high, your doctor may diagnose you with diabetes. The information contained in this article is for informational purposes only. It should never be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition. Medicare Part BandMedicare Part Dgenerally cover the services and supplies needed to control diabetes. Heres a breakdown of how Medicare covers diabetes. Medicare Part B covers the fasting blood glucose test, which is a diabetes screening. Medicare covers two diabetes screenings each year for beneficiaries who are at high risk for diabetes. High risk factors for diabetes include: high blood pressure, history of abnormal cholesterol and triglyceride levels, obesity, or a history of high blood sugar. If diabetes runs in your family, you may also need regular diabetes testing. Your doctor may also recommend services that Medicare doesnt cover. You generally pay nothing for these diabetes tests if your doctor accepts the amount approved by Medicare for the diabetes screening. However, you may have to pay 20% of the amount approved by Medicare for the doctors visit. If your doctor diagnoses you with diabetes, Medicare covers the supplies you need to control your diabetes, including blood sugar testing monitors, blood sugar test strips, lancet devices and lancets, and blood sugar control solutions. Medicare Part B may cover an external insulin pump and insulin Continue reading >>
Diabetic Equipment & Supplies
• Recipients with Medicare Part B must obtain diabetic testing supplies from a Medicare medical supplier or pharmacy. • Diabetic equipment and supplies other than testing supplies may be obtained from a medical supplier or pharmacy. • Disposable blood glucose meters include any necessary test strips and calibration solution or chips • Disposable blood glucose meters are limited to four per calendar month • Blood glucose test strips may not be billed within 30 days of disposable blood glucose meters • Recipient has insulin dependent Type I diabetes • Document specific reason blood ketone testing is required, including any history of ketoacidosis or complicating conditions likely to lead to ketoacidosis • Specify why urine testing is not sufficient (urine testing is known by DHS to be less accurate, documentation must be clear as to why very accurate results are needed) • State frequency of testing and expected duration at this frequency • Recipient must have a blood glucose monitor capable of blood ketone testing. If the recipient has a blood glucose monitor that is less than five years old, providers must submit a claim with an attachment explaining the need for the replacement monitor with the approved PA for the blood ketone test strips in the notes field • Completion of a comprehensive diabetes education program • On a program of at least three injections of insulin per day, with frequent self-adjustments of dose, for at least six months • Documented self-testing an average of at least four times per day • Has one of the following: • Elevated glycosylated hemoglobin level of HbA1c greater than 7.0 percent • History of recurring hypoglycemia less than 60 mg/dL • Wide fluctuations in blood glucose before mealtime • Dawn phenomenon wi Continue reading >>
Medicare Coverage Of Diabetes
| Licensed since 2012 Print According to the Centers for Disease Control and Prevention (CDC), about 29 million Americans suffer from diabetes, or approximately 9.3% of the population (all ages in 2012). The Centers for Medicare & Medicaid Services (CMS) says that diabetes is a disease where blood glucose levels are higher than normal. There are many people who don’t know they have diabetes, and Medicare covers screening tests to check if you do. If you have been diagnosed with diabetes and are enrolled in Original Medicare (Part A and Part B), you may have questions about Medicare coverage of diabetes treatment, tests, and supplies. Here’s what you need to know. What diabetes screenings and exams does Medicare cover? Medicare Part B (medical insurance) will cover lab tests to check for diabetes if you have one of the following risk factors: High blood pressure History of abnormal cholesterol and triglyceride levels Obesity History of high blood sugar Also, Part B will cover the diabetes screenings if two or more of the following apply to you: Age 65 or older Overweight Family history of diabetes History of gestational diabetes (diabetes during pregnancy), or delivery of a baby who weighs more than nine pounds If your doctor orders a screening test, Medicare Part B will pay for up to two diabetes screenings in a 12-month period and you won’t have to pay anything for these tests. If you’ve been newly diagnosed with diabetes, you may want to consider attending diabetes self-management training, which Medicare Part B helps to cover, to help you manage and cope with diabetes. If you have already been diagnosed with diabetes and have Medicare Part B, Part B covers certain screenings, listed below. You’ll generally need to pay a copayment and for 20% of the Medicare Continue reading >>
Medicare Part D (federal Prescription Drug Benefit) Faqs
1. How does Medicare Part D affect pharmacists? Medicare Part D chiefly affects the way pharmacists get paid when dispensing drugs to Medicare/Medi-Cal dual-eligible recipients and all other Part D eligible recipients. Beginning January 1, 2006, most outpatient drug claims and some medical supply claims used in the administration of insulin (like insulin syringes), will be submitted to and paid by the recipient’s Prescription Drug Plan (PDP) or Medicare Advantage Prescription Drug (MAPD) Plan. Most pharmacy claims submitted to Medi-Cal for dates of service on or after January 1, 2006 will be denied. 2. How do I know which plan the recipient uses? The recipient should have either a PDP or MAPD card, much like the Medi-Cal Benefit Identification Card (BIC). That card will contain information needed to bill the drug plan. If the recipient does not have a PDP or MAPD card, run the recipient’s BIC through the Medi-Cal eligibility system. The eligibility system may show information about the plan the recipient has chosen. Additionally, NDCHealth is contracted with the Centers for Medicare & Medicaid Services (CMS) for Eligibility Facilitator Services. They will provide real-time insurance coverage information to pharmacies to give them the ability to submit claims to the right PDP and any supplemental plans in the correct order. For more information, visit the NDCHealth Web site. 3. I heard Medi-Cal will still pay for some drugs. What drugs are paid for, and under what conditions? Even though there are nine categories of drugs excluded from coverage under Part D, drug plans have the option of covering drugs within those categories. Medi-Cal will continue to pay providers’ claims for the six “Part D excluded” categories of drugs that it currently covers. The categori Continue reading >>
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Diabetes Health Coverage: State Laws And Programs
Diabetes Health Coverage State Laws and Programs Diabetes Health Coverage: State Laws and Programs This is a policymaker and consumer guide to state insurance mandated coverage, Medicaid coverage and state-sponsored diabetes programs. It was published 2011and updated material was added January 2016 All state law diabetes mandates and minimum coverage requirements for state-regulated health insurance policies. The tables include the enacted state laws passedsince the firstmandates inCalifornia (1981) and New York (1993). Use links below to go directly to state-based information: State Medicaid diabetes coverage terms and conditions. All Children's Health Insurance Program (CHIP) diabetes coverage. Contact information and an overview of federal funding provided by the Centers for Disease Control and Prevention (CDC) to state-sponsored diabetes prevention and control programs (DPCPs). DPCPs represent the front line in battling diabetes in most states. An overview of other state activities and initiatives, such as creation of diabetes coordinator positions in the executive branch to fight diabetes. Federal Health Reform.The federal Affordable Care Act (ACA) signed March 2010, has led to changed and expanded coverage termed "EssentialHealth Benefits." Newly Released: NCSL Survey:Diabetes Drug coverage: A new survey of2016 Insurance Plans in 50 states, examining 1) patient access to the scores of diabetes drug treatments and2) results in the 46 states with laws mandating or offering diabetes coverage. NCSL original research, published summer 2016. [Read the report] December 2015: " Diabetes: Addressing the Costs; A 50-State Budget Survey for FY 2014 ." NCSL released its latest diabetes report, taking a closer look at programs and budget appropriations that play a role in con Continue reading >>
Cgms Can Be Durable Medical Devices, Cms Rules
The ruling paves way for partial Medicare and Medicaid coverage for qualifying CGMs. On January 12, the Centers for Medicaid and Medicare laid out criteria for a continuous glucose monitor (CGM) to be considered a “durable medical device.” In doing so, federal regulators opened up the possibility that Medicaid and Medicare programs could cover at least some of the cost for qualifying CGMs and supplies. sponsor The ruling makes clear, however, that not all CGMs qualify for this new distinction. Only those that the FDA declared accurate enough to be a replacement for fingersticks in making decisions on insulin dosing will be covered. While most CGM owners already use the devices to replace fingersticks, only the Dexcom G5 Mobile has been declared a fingerstick replacement by the FDA. Therefore, the G5 Mobile currently is the only CGM on the market to be defined as a durable medical device under the new CMS ruling. Read “FDA Approves First Receiver-less CGM.” This rule change comes less than a month after the FDA decision on the the G5 Mobile, and one can assume that the FDA ruling influenced the timing of the CMS decision. This past year also saw FDA approval of the Medtronic 670G, the first automated insulin pump system on the market; the 670G technology depends upon an integrated CGM for making automatic insulin delivery adjustments. Such regulatory wins for CGM technology most likely weakened the case for denying coverage for CGMs. The CMS ruling makes clear that CGMs not approved as replacements for fingersticks still will be considered “non-therapeutic” CGMs. According to the FDA, these CGMs should officially only be used to supplement fingerstick readings. It seems likely, however, that CGM makers will now set the bar for the same FDA approval granted to Continue reading >>
Are Syringes And Needles Covered Under Medicare?
Are syringes and needles covered under Medicare? Around 9 million Americans use syringes and needles to help stabilize their medical conditions from home, amounting to over 3 billion total used each year. Injection devices are commonly used to administer insulin for diabetes patients, but can also be used for a variety of medical conditions such as allergies, hepatitis, arthritis, HIV/AIDS and cancer. These medical supplies typically range in sizes depending on the volumes and lengths needed to treat a diagnosed ailment. 6 millimeters, 8 millimeters and 12.7 millimeters are mainly used for at-home injections, however it’s important to consult with your doctor regarding which variety is necessary for your condition. Does Medicare cover syringes and needles? Normally Medicare Part B covers durable medical equipment, or DME needed for treatment, but it does not cover hypodermic objects needed for insulin or other medical usage. However, Medicare Part D – prescription drug coverage – insures any injectable objects along with other insulin supplies needed for diabetes, such as alcohol swabs, gauze and inhalant devices. Payments may vary depending on your private insurance plan and monthly Medicare Part D premium, but you’ll pay no more than five percent of your prescription costs after spending a certain amount out of pocket each year. How do I qualify for coverage? Anyone enrolled in the Medicare program with either Part A or B can obtain drug coverage with Part D, regardless of income. There are no physical exams necessary, and you cannot be denied enrollment due to health reasons or previous drug prescriptions. Other people included are: Ages 65 and older and are United States Citizens or permanent residents Under 65 years old with certain disabilities People with Continue reading >>
Mc Sup
This section contains information about medical supplies, lists of products and program coverage (Welfare & Institutions Code [W&I Code], Section 14105.47). The information provided in this section applies to the medical supplies included on the lists below. The following spreadsheet contains all medical supply billing codes, units, quantity limits and maximum allowable product cost (MAPC): · List of Medical Supplies: Billing Codes, Units and Quantity Limits The following are medical supply lists of contracted products for certain HCPCS billing codes and for diabetic test strips and lancets: · List of Contracted Diabetic Test Strips and Lancets · List of Contracted Sterile Needles (HCPCS A4215) · List of Contracted Tracheostomy Supplies Program Coverage Medi-Cal covers certain medical supplies when provided on the written prescription of a physician. A recipient’s need for medical supplies must be reviewed by a physician annually. Medical supplies are covered for chronic outpatient hemodialysis provided in renal dialysis centers and community hemodialysis units or for home dialysis, but are included in the all-inclusive rate paid to the center or unit and are not separately reimbursable. Medical supplies provided to inpatients receiving Nursing Facility Level A (NF-A) services or Nursing Facility Level B (NF-B) services, whether or not rendered in a hospital setting, are reimbursable only for the medical supplies listed below and only when required by a specific patient for that patient’s exclusive use. · Diabetic test strips and lancets · Condoms · Diaphragm · Infusion Supplies – heparin and saline flush and HCPCS codes A4223, A4305, A4306, A4230 – A4232, A9274, B9999 and S1015 Medical supplies provided to inpatients Continue reading >>
Does Medicare Cover Diabetes-related Medical Expenses?
Medicare covers supplies for people with diabetes, whether or not they use insulin. These include glucose testing monitors, blood glucose test strips, lancet devices and lancets, and glucose control solutions. There may be some limits on supplies or how often you get them. Medicare also covers the cost of therapeutic shoes, self-management training, nutrition counseling, flu and pneumococcal pneumonia shots, and glaucoma screening for people with diabetes. For more information, see Medicare Coverage of Diabetes Related Supplies and Services at the Medicare Web site. In addition, Medicare beneficiaries aged 65 years and older who have diabetes and haven’t had a medical eye exam in the past three years can receive a free comprehensive eye exam and up to one year of follow-up care for any condition diagnosed at the initial exam. Does Medicaid cover diabetes-related medical expenses? Medicaid is a state administered program and each state sets its own guidelines regarding eligibility and services. Visit the Medicaid Site for Consumer Information to locate information by state. How do I figure the cost of diabetes for my company? Where can I find free or low-cost diabetes coverage and services? The Bureau of Primary Health Care within the Health Resources and Services Administration (HRSA) has a nationwide network of community-based health care centers that provide primary health care services at little or no cost. Hospitals and other health care facilities participating in HRSA’s Hill-Burton Program provide free and low-cost services to eligible individuals. The State Children’s Health Insurance Program (SCHIP) provides free or low-cost health insurance for children. The Partnership for Prescription Assistance provides information about public and private patient assi Continue reading >>
California Department Of Managed Health Care > Health Care In California > I'm Insured, Now What?
Health plans must cover basic health care services, which include: doctor visits,hospital services, inpatient services (when you have to stay overnight in the hospital), and outpatient services(such as minor surgery in a surgery center). Other basic services include: Diagnostic laboratory tests,such asblood tests, STD (sexually transmitted diseases) tests, pregnancy tests, and some cancer screening tests Diagnostic services, such as x-rays and mammograms Preventive and routine care , such as vaccinations and checkups Mental health care for some serious conditions, including serious emotional disturbances of a child Emergency and urgent care , whetheryou are in your health plan's service area or not Rehabilitation therapy, such as physical, occupational, and speech therapy Some home health or nursing home care after a hospital stay Additional Benefits that Health Plans Must Cover Standing referrals for patients with AIDS (you do not have to get a referral and approval each time you see an AIDS specialist) Routine costs of clinical trials for cancer treatment Prosthetic devices or reconstructive surgery after a mastectomy (removal of a breast) Prosthetic devices to restore a method of speaking for a patient after a laryngectomy (removal of the vocal cords), not including electronic voice-producing machines. Reconstructive surgery to correct or repair birth defects, developmental abnormalities (something that is not normal in the way a child grows), trauma or injury, infection, tumors, or disease to improve function (the way a part of the body works) or to create as normal an appearance as possible. Services related to diagnosis, treatment, and management of osteoporosis (weak bones), including bone mass measurement and other FDA-approved tests and medications General ane Continue reading >>
Prescription Drugs
Covered California Prescription Drug Resources by Health Plan The table below shows where to find the prescription drug list (or formulary) and customer service phone number for each Covered California health insurance plan. The Patient Protection and Affordable Care Act requires health insurance plans to cover prescription drugs (also known as prescription medications). This means prescription drugs will be available to enrolled members of a health plan at reduced or no charge. The set of prescription drugs covered by a health insurance plan may also be called a formulary, prescription drug list, outpatient prescription drug list or select drug list. (Plans do not cover every prescription drug available, but are subject to regulations that require drug coverage in major drug categories.) All Covered California health insurance plans will: Use the same names for drug tiers. No matter which health plan you choose, the drugs will be labeled as Tier 1 (generic drugs), Tier 2 (preferred drugs), Tier 3 (non-preferred drugs) or Tier 4 (specialty drugs). Charge no more than up to $250 per month for one 30-day supply for Silver 70, Gold 80 and Platinum 90 plan members and no more than up to $500 per 30-day supply for Bronze 60 plan members. These costs apply to Tier 4 (specialty drugs). Drugs in lower tiers have lower costs. Maintain a dedicated prescription drug customer service line where current and prospective members can call for help. Describe the appeals and exception process clearly on the formulary, so members understand what to do if a drug they need is not covered. Provide current and prospective members with an estimate of the out-of-pocket cost for specific drugs. Prescription Drugs Not Covered by a Health Plan If a member needs a drug that their health insurance Continue reading >>
Medicare And Diabetes: What Is Covered?
Medicare is the federal health insurance program for people age 65 and older as well as people under age 65 with disabilities and those living with End-Stage Renal Disease. Original Medicare, the most common way to receive Medicare is comprised of part A and part B. Part A is hospital insurance and will cover most medically necessary hospital, home health, skilled nursing facility, and, hospice care. Part B is medical insurance paid for by a monthly premium and covers most medically necessary doctors’ services, durable medical equipment, preventive care, hospital outpatient services, lab tests, x-rays, mental health care, and some home health and ambulance services. You can choose to also get Medicare Part D which is prescription drug insurance and is provided only through a private insurance company that has a government contract. There is also the alternative option to get a private Medicare plan called a Medicare Advantage Plan or Medicare Part C, which generally includes Part D coverage. The Medicare Plan A deductible for 2017 is $1,316 and depending on how long your stay is, you may have to pay an additional amount. The Plan B monthly premium for most Americans in 2017 is $109, though people pay more depending on income level. You can find out your monthly premium by calling Social Security at 1-800-772-1213. You may also have to pay a deductible for Part B. In 2017 the Part B deductible is $183 and after you pay the deductible Medicare pays 80 percent of the Medicare-approved cost of your medically necessary supplies and services. You would pay the 20 percent coinsurance payment. Once the deductible has been met, you cannot be charged to pay more than your 20 percent coinsurance amount and this is the case whether you pick up your diabetes supplies at a local st Continue reading >>
Is My Test, Item, Or Service Covered?
How often is it covered? Medicare Part B (Medical Insurance) doesn’t cover insulin (unless use of an insulin pump is medically necessary), insulin pens, syringes, needles, alcohol swabs, or gauze. Medicare prescription drug coverage (Part D) may cover insulin and certain medical supplies used to inject insulin, like syringes, gauze, and alcohol swabs. If you use an external insulin pump, insulin and the pump may be covered as durable medical equipment (DME). However, suppliers of insulin pumps may not necessarily provide insulin. For more information, see durable medical equipment. Your costs in Original Medicare You pay 100% for insulin (unless used with an insulin pump, then you pay 20% of the Medicare-approved amount, and the Part B deductible applies). You pay 100% for syringes and needles, unless you have Part D. To find out how much your specific test, item, or service will cost, talk to your doctor or other health care provider. The specific amount you’ll owe may depend on several things, like: Other insurance you may have How much your doctor charges Whether your doctor accepts assignment The type of facility The location where you get your test, item, or service Continue reading >>
California To Hear Bill Ab 447 To Authorize Medi-cal To Cover Cgm
Home Innovation California to Hear Bill AB 447 to Authorize Medi-Cal to Cover CGM California to Hear Bill AB 447 to Authorize Medi-Cal to Cover CGM Posted by Karrie Hawbaker On April 13, 2017 In Innovation At Medtronic, we know how valuable access to continuous glucose monitoring (CGM) can be. Weve heard countless stories from patients about the changes its made to daily diabetes management and how its helped improve their lives. Because of this, Medtronic, as well as others have been trying to ensure CGM coverage for Medicaid recipients in states across the country. This includes California and on April 25, 2017, the California Assembly Health Committee will hear an important bill in Sacramento. The bill, AB 447, would authorize Medi-Cal to cover CGM as medically necessary and allow access like most major private health plans in California CGM is proven technology for people with diabetes who are unable to adequately control their blood glucose levels using finger-stick tests and are in jeopardy of incurring life-threatening complications. If you are a California resident, we urge you to communicate now with your state assemblymember and senator. If you dont know who your state legislators are, you can find them at this website by typing in your address: Most importantly, communicate with members of the Assembly Health Committee who will hear AB 447 on April 25th. They will decide if the bill can move forward and be considered by the Assembly Appropriations Committee. Heres a link to the Health Committee Members . Office Visit: Schedule a meeting with your state legislator in their home district office. Personal visits are the most effective way to convey your passion about the benefits of CGM to your legislator. Personal Letters: Send a personalized letter on your le Continue reading >>
