Pharmacy Plan Coverage

How We Cover Self-administered Drugs Given in Outpatient Settings

Under Medicare Part A (inpatient), drugs are covered when provided during acute inpatient stays if Medicare requirements are met. Under Medicare Part B (outpatient, emergency room, observation hospital stays), drug coverage is limited to drugs that are not usually self-administered.

When you’re undergoing outpatient treatment, you may be given medication Medicare considers self-administered. Medicare defines self-administered drugs as medications the patient could, in another setting, take themselves (examples include but are not limited to blood pressure, cholesterol, or diabetes medications).

Some hospitals will allow medications brought from home in their original pharmacy container, properly labeled, and positively identified to be used with a physician order. If your medications from home can be used, you will not receive a bill for these medications. When you’re going to the hospital for outpatient admission, to see a physician, receive outpatient services, or use the emergency room, always try to bring any medication (in its original pharmacy container) you have been taking.

If you forget to take your medications with you or the hospital is not able to administer your home medications, the hospital staff will provide you with doses that are required during your stay. In order to remain compliant with Medicare regulations related to the billing of these drugs, the hospital is required to submit these self-administered drugs as non-covered items on your bill to Medicare plan (i.e. HealthTeam Advantage). You will receive a bill from the hospital following payment of your claim by HealthTeam Advantage. In addition to any deductible and co-insurance due, this bill will reflect the charges for unpaid self-administered drugs. These medications will be identified with a Revenue Code (also called Rev Code) of 0637 on the bill. Even though these medications cannot be covered under Medicare Part A and Part B, because you are a member you do have coverage for these medications under your Part D benefit.

Here are the steps you need to follow to request coverage under your Part D benefit:

1. When you receive the hospital bill please pay the bill in full or reach out to the hospital to setup a payment plan. You will need to pay the entire amount that is being billed.
2. Make copies of the hospital bill and any receipts you have for the stay.
3. Mail the copies, along with the documentation of any payments you made, Prescription Drug Claim Form, and a note requesting reimbursement to:

RxAdvance/HealthTeam Advantage
Attn: DMR Department
PO BOX 1318
Westborough, MA 01581

Please note you must submit your claim to us with 60 days of the date you received the medication.

When we receive your request, we will let you know if we need any additional information. If no additional information is needed, we will consider your request and make a coverage decision. We will reimburse you for our share of all Part D eligible medications. This means we will send you a check for the amount you paid for the covered medications minus your Part D copay or coinsurance.

You may also contact your Healthcare Concierge if you have any questions. If you don’t know what you should have paid, or you receive bills and you don’t know what to do about those bills, we can help. You can also call if you want to give us more information about a request for payment you have already sent to us.