Compound drugs falling under part b?

pdagosti

pdagosti

New Member
Hi all, been on a advantage plan for 2nd year. My wife has the same insurance and has a internal pain pump that is filled with compound drugs every quarter. Recently we been getting $235 bills after paying specialist 35 copay. I inquired first with doctors office and then with insurance. Insurance told me compound drugs fall under part b and that was my 20%. I thought the $35 copay would cover everything? So, does anyone know if that is correct compound drugs falling under part b? If so then probally better off going to traditional medicre with supplements.
So confusing on what is best.
 

Hi, @pdagosti I don't know the full answer to your question (fairly new to the whole medicare thing myself) but I would think a med would not be covered under part B; isn't that for the MD office visits? Probably someone more knowledgeable can give a better answer.

In the meantime, welcome to the forum and I hope you get the answers you need.
 
Not sure if I'm understanding you correctly....but do you have a Part D plan w/your Advantage plan?
Part D helps w/your meds.
 

There are some meds that are covered by Part B,

and those are not covered by Part D, which covers the majority of meds.

That is likely correct that the one mentioned, is under Part B, because of the manner in which it is given, as well as it is compounded, as you said. (Made up as a special combination that the patient needs)

I don't know too much about the "advantage" plans, or which plan you'd be better off with, overall.

Nor do I know the exact rules for changing from an advantage plan,
to the original traditional Medicare, which is Parts A (inpatient for hospital) and B( outpatient doctor visits.)

I believe that you can change, but there are guidelines on how and when. Likely during the "open enrollment" period, Oct. thru first week in Dec. every year.

But again, I don't know the specific method or timing on switching, or even if a specific person would be better off with which one, if they have specific medical expenses, as you do.



Medicare.gov has lots of good info, and you might find very helpful and informative articles there. It's a pretty user-friendly site.

And perhaps someone else at our forum might know more.
 
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dobielvr said:
Not sure if I'm understanding you correctly....but do you have a Part D plan w/your Advantage plan?
Part D helps w/your meds.
Click to expand...

I think Part D is only to add to the traditional Medicare (Part A and B) for those of us who do not buy an Advantage plan, which replaces traditional Medicare.

If someone opts for an Advantage plan, instead of traditional Medicare, then they don't have the separate Part D and don't buy one, as it would be duplication for them, because advantage plans include prescription drugs.
 
This type of compounded med, might not be paid for by a Part D plan. I don't know, but none of the plans pay for all meds.
It is likely to be a Part B item.
 
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pdagosti said:
Hi all, been on a advantage plan for 2nd year. My wife has the same insurance and has a internal pain pump that is filled with compound drugs every quarter. Recently we been getting $235 bills after paying specialist 35 copay. I inquired first with doctors office and then with insurance. Insurance told me compound drugs fall under part b and that was my 20%. I thought the $35 copay would cover everything? So, does anyone know if that is correct compound drugs falling under part b? If so then probally better off going to traditional medicre with supplements.
So confusing on what is best.
Click to expand...
It is usual for all medical costs, to be divided, as far as the bills go.
There are very often separate bills and separate charges, for each different part of any one medical service, and also from the provider doctor(s), for one service that the patient gets.
They divide them up, so yes, we have to expect multiple bills, including a bill from the doctor (and sometimes from more than one doctor, if more were involved in any part of the process, even if you didn't see all of them, such as specialists who interpret test results, etc)

Each charge is billed separately to whichever Medicare plan or plans that you have, and then, each remaining charge is billed to you.

Again, I am not an expert , and this is ALL, just general info;

I know much less about Advantage plans than traditional Medicare, so I dont know exactly how they do things. It does surprise me that there's still a 20% if you have Advantage, as you believe you do. I thought that Advantage plan means that you do not need to buy a separate Medigap plan in order for those 20% charges to be paid, or a Part D.
 
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pdagosti said:
Hi all, been on a advantage plan for 2nd year. My wife has the same insurance and has a internal pain pump that is filled with compound drugs every quarter. Recently we been getting $235 bills after paying specialist 35 copay. I inquired first with doctors office and then with insurance. Insurance told me compound drugs fall under part b and that was my 20%. I thought the $35 copay would cover everything? So, does anyone know if that is correct compound drugs falling under part b? If so then probally better off going to traditional medicre with supplements.
So confusing on what is best.
Click to expand...
I was a Medical billing specialist prior to retiring. Copay is just that, copay...doesn't cover anything extra. It can be very confusing to patients. Part B Medicare covers 80% of procedures leaving the patient resp for 20%. Do you guys have Medicare Part D which covers prescription drugs? It's all confusing to patients and in my opinion, reps that sign you up for different plans, don't do a good job in informing patients of what's covered and what's not.
 
If the OP or anyone else, actually has one of the Medicare Advantage plans, I don't think they need or buy any Part D.
It's different from regular, traditional Medicare.

And certain meds, that are compounded and/or delivered by medical methods other than oral script meds,
are often not Part D meds anyway. Some of them are specifically billed as Part B.

Even though we think of Part B as for outpatient medical doctors and office visits, which it primarily is.
 
I don't think that people who have a Medicare Advantage plan, are even allowed to purchase Part D.
That would be, to protect them from buying duplicated plans, as the Advantage plans have their own drug coverages included. I am pretty sure that's the way it works.
 
Kaila said:
I don't think that people who have a Medicare Advantage plan, are even allowed to purchase Part D.
That would be, to protect them from buying duplicated plans, as the Advantage plans have their own drug coverages included. I am pretty sure that's the way it works.
Click to expand...
I'm pretty sure I have Part D w/my Advantage plan.
At no cost to me.
 
Hi All and Thank You for the responses. Yes Part d comes with my Advantage plan, but was told because it's compound drug it is billed to part b pays 80% and me 20% on top of co-pay. Since I'm farily new to medicare our rep said it worked like private insurance (not), just pay the $35 co pay just like I did when working and had private insurance. Just thought the office was billing wrong codes. Our open enrollment is Oct -Dec, so I'll have to reevaluate. Advantage plan is working ok, except for this recent surprise and now worry about future suprises. Adding that cost it may be better to switch to traditional medicare with supplements.
 
Thanks to all of you, for tweaking and correcting, part of my post info.!:geek:

What I didn't know, is that they still call it Part D, when the drug coverage is included in a Medicare Advantage Plan.
As I said in above posts, I know less about the Advantage plans, than about the traditional Medicare.

I knew that you don't separately buy a stand-alone Part D,
if you have an Advantage plan.

(As I do buy a stand-alone Part D, in order to have it in addition to the traditional Medicare, which is parts A and B, and is without any meds coverage itself, except for the meds that are specifically covered by Part B, instead of D.)
 
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pdagosti said:
Advantage plan is working ok, except for this recent surprise and now worry about future suprises. Adding that cost it may be better to switch to traditional medicare with supplements.
Click to expand...
Unless you already know about them, future surprises might include the required prior approvals for many services and treatments, and the non-coverage of any/all possible providers who are not in the network of your specific Advantage plan.

However, costs you will also want to consider, when you decide, in the autumn, are your dental and eyeglasses, hearing items.....any/all of these types of medical items, which your specific Advantage plan might pay part of, that you would pay out-of-pocket, when needed, if you go to traditional Medicare (with supplements you choose) instead.
Of course, weighing those expenses against the premiums, might be warranted, for each of us.
 
By the way, premiums for Part D stand-alone plans,
are quite low, especially when compared to any other Medicare premiums, or premiums for any other medical or other insurances.

And the cheapest stand-alone Part D plans, are sometimes quite adequate, for many people. The expensive ones (while still less than any of the other premiums) do not cover all meds, either, and are not even any cheaper for some specific meds.
Just general fyi, not for anyone's specific situation.
 
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I believe the rules are that if you choose an Advantage plan when you start receiving Medicare you have a certain amount of time that you can choose to switch back to original Medicare with guaranteed issue rights. I believe it's 6 months to a year, somewhere in that time frame. After that time has lapsed you can go back to original medicare but you no longer have guaranteed issue rights and would be subject to medical underwriting to get a policy.
 


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