In addition to Part D drug coverage, Medica members may have the following prescription and over-the-counter drug coverage under their Medica pharmacy benefits. Under Medica’s Part D plans, these drugs are covered under enhanced pharmacy benefits and do not imply
that they are a covered Part D medication.
The type of pharmacy benefit a Medica member has is determined by the insurance product in which the member enrolled. Specific pharmacy benefit information is included in a member’s Evidence of Coverage (EOC) documents that they receive when enrolling into a Medica benefit plan.
Medica Part D members have Part B coverage for many Part B covered medications and supplies from a network pharmacy. Common Part B pharmacy provided medications and supplies include:
- nebulized drugs
- diabetic blood sugar testing devices & supplies
- oral oncology drugs
- transplant rejection medications
- home infusion drugs
- miscellaneous Part B drugs
Exact coverage of Part D or Part B medications cannot be defined at the medication level alone. Place of service, indication for use, Medicare enrollment date, and various other reasons may impact if a medication is covered under Part D or Part B.
Certain medications are covered under Medicare Part B or Medicare Part D. Prescription claims processed at a pharmacy do not contain enough information to determine the benefit a drug will be paid at. Medica uses a Part D vs Part B Prior Authorization to halt these
prescription claims prior to paying the pharmacy claim. Additional information must be provided on a coverage determination form to determine the correct Medicare benefit to process the claim under. All Part B vs Part D prior authorizations are located in our Medicare
Part D Prior Authorization Guidelines on www.medica.com (see Prior Authorizations above for more information).
A member’s Part B co-payment may vary depending on their pharmacy benefits in their plan. Part B co-payment information is included in a member’s EOC documents. Part B drug costs do not count toward a members Total Drug Spend for Part D or part of a Member’s Part D True-Out-of-Pocket Costs (TrOOP).
Medicare and Medicaid Dual-Eligible Medica members have coverage for certain over-the-counter (OTC) drugs as part of their Medicaid pharmacy benefits.
View the list of OTC drugs Medica covers for Minnesota State Public Programs.
Return to Pharmacy Services.