Health library

It is in your best interests to educate yourself about your Medicare plan.

For many people, participation in Medicare is an answer to prayer. Sometimes, however, understanding individual benefits within an extremely complex federal government program can be a less-than-heavenly experience.

One example garnering attention lately is the coverage policies surrounding those drugs classified by Medicare as outpatient drugs.

What are outpatient drugs?

Medicare defines outpatient drugs as those that are usually self-administered by the patient, but which may also be administered by a health care provider when needed. They may be prescription drugs, such as insulin, or over-the-counter drugs, like an inhaler for treating asthma. Medicare Part B generally does not cover drugs classified as outpatient drugs.

Bound by the same federal mandates under Medicare that regulate hospitals across the nation, Grande Ronde Hospital (GRH) is required by Medicare to bill our patients directly for all outpatient drugs administered during hospital visits.

The good news is that if you have elected to enroll in the new Part D Medicare Prescription Drug Plan, you can file what is known as an out-of-network claim with Medicare for reimbursement of these charges. However, if Medicare chooses to deny the appeal, you will still be responsible for the charges. And you should also know that Part D plans were intended for retail pharmacies, not hospitals. GRH is not licensed as a retail pharmacy and is therefore defined by Medicare as out-of-network.

How GRH is helping

GRH continues to work to improve patient communication regarding this issue. We strive to help our patients become better informed about Medicare’s policy on this subject. We provide our patients with a short, easy-to-understand explanation of this Medicare-mandated policy on self-administered drugs. We have also posted this statement on our website. Our staff members are here to help as much as they can, but we believe it is ultimately in your best interests to educate yourself about your Medicare plan.

If you have Medicare Part D, your best resource for help navigating Medicare’s Prescription Drug Program is the agent with whom you enrolled. More than anyone else, your agent is equipped to fully explain your particular plan.

Another good resource for help with fully understanding the benefits of Medicare is Community Connection of Northeast Oregon. They have trained staff dedicated to guiding you through the intricacies of Medicare. In Union County, Community Connection is located at 1504 Albany in La Grande and may be reached by calling 541-963-7532. Two other good resources for help online are www.eldercare.gov and www.medicare.gov/pdphome.asp.

---

Understanding your prescription drug benefits

Medicare provides limited coverage for outpatient drugs. Drugs that are usually self-administered by the patient, such as those in pill or tablet form or those used for self-injection, are generally not covered by Medicare Part B.

If a charge for a particular drug is denied because the drug is subject to the self-administered drug exclusion, you will be responsible for the charge on your bill. You may file an appeal with Medicare for any charges denied under the self-administered drug exclusion.

If you have elected to enroll in the new Part D Medicare Prescription Drug Plan, you will need to file a claim with them for reimbursement for your medication. Grande Ronde Hospital (GRH) is required by Medicare to bill you directly for prescription and over-the-counter drugs administered to you during your visit.

If you think your medications will be covered by your Part D plan, you can file an out-of-network claim with your prescription drug plan to be reimbursed for these drugs. GRH is considered out-of-network because Part D plans are intended for retail pharmacies, and we are not licensed as such.

Please refer any Part D-specific questions back to the prescription drug plan with which you have enrolled.

If you have any questions concerning Medicare coverage of drugs, please refer to your Medicare handbook or call 800-MEDICARE (800-633-4227).