In deciding whether to go with Medicare Part D and, if so, which Part D plan to join, cancer patients have some special things to think about. As noted before, most prescription drugs are covered through the new Medicare Part D benefit. This includes drugs used to treat high blood pressure, high cholesterol, arthritis, depression, and other health conditions. These medicines can be pills taken by mouth, inhaled drugs (like those used to treat asthma), and drugs that are injected by patients (like insulin for people with diabetes). A general rule is that Part D covers any medicines prescribed by your doctor that you get at your local pharmacy.

Many cancer drugs will still be covered under Part B.

Medicare Part B covers doctor visits and outpatient hospital services. Part B also covers about 500 drugs that are infused or injected in a doctor's office or treatment center. Many chemotherapy drugs and the anti-nausea drugs used along with chemotherapy are given through an intravenous (IV) infusion in a doctor's office. This means they are still covered under Part B.

The difference in coverage for cancer drugs under Medicare Part B and Medicare Part D is blurred when it comes to chemotherapy drugs given by mouth (oral drugs) and anti-nausea drugs given by mouth (oral drugs). Some of these drugs are covered under Part B, but others are covered under the new Part D drug benefit. The rule of thumb for sorting out these coverage rules is as follows:

Oral cancer treatment drugs

Some cancer drugs taken by mouth (oral drugs) as part of chemotherapy are covered under Part B. For the most part, oral cancer treatment drugs are covered under Part B if they are used instead of the same drug given through an IV in your doctor's office. In other words, if your doctor has a choice between an oral drug and the IV drug, then the oral drug is covered under Part B. Oral cancer treatment drugs that do not have an equal form of the drug that is given through an IV in your doctor's office would be covered under Part D and not Part B.

Oral anti-nausea drugs

The rule for oral anti-nausea drugs is much the same. Anti-nausea drugs are often used as part of chemotherapy. If your doctor has a choice between an oral anti-nausea drug and the same drug as an IV therapy and the drug is given within 48 hours of chemotherapy treatment, then the oral drug is covered under Part B. Oral anti-nausea drugs that do not have an equal form of the drug that is given through an IV in your doctor's office are covered under Part D and not Part B. Also, if an anti-nausea drug is prescribed for a patient who is not known to have cancer, then the drug is covered under Part D rather than Part B.

What does all this mean?

Many patients find the rules for the difference between Medicare coverage under Part B and Part D hard to understand. For patients with cancer, the rules can be even more confusing because some cancer drugs are already covered under Part B.

As a general rule, drugs that patients can inject on their own without help from a doctor or nurse, or that are not taken as part of chemotherapy, are not covered under Part B. These drugs are covered under the Part D drug benefit.

If you have more questions, your doctor and his and her office staff should be able to help you sort through the coverage rules. They can help you figure out whether a drug is covered under the Medicare Part B benefit or the Medicare Part D drug benefit.

Why is this issue important?

It’s important to understand the difference between drug coverage under Part B and coverage under Part D. That's because your out-of-pocket costs will vary depending on which part covers which drug.

For services covered under Medicare Part B, the government pays 80% of all costs after patients meet a yearly deductible (the deductible amount is set by Medicare every year). Under Part B, patients must pay 20% of the drug's cost no matter how high their total medical bills run. Many people with Medicare have supplemental or Medigap insurance – or other ways – to cover their out-of-pocket costs under Part B.

In contrast, the Part D benefits vary from plan to plan with regard to:

• the amount of the annual deductible
• the cost-sharing for expenses each year
• the extent of coverage in the so-called "donut hole" where there is no government assistance

But under Part D, after you pay a certain amount of drug expenses, you will pay only 5% of all ongoing drug costs for the rest of the year. Again, this amount is set every year. See the section "What is the coverage gap, and what do I have to pay?" for the 2009 example.

You should also know that some cancer drugs are clearly covered under Part B, like those given through an IV in your doctor's office. Because of this, you might not be able to find all of the drugs that are part of your cancer treatment on a Part D plan's formulary. (The list of drugs that are covered under a plan is called a formulary; see the section "Formularies and drug coverage" for more information.) If you are deciding whether to enroll in a drug plan and you don't see a drug you need on a plan's formulary, call the plan and ask about its coverage rules.

What about off-label drugs and Part D?

What is off-label drug use?

When the Food and Drug Administration (FDA) approves a new drug, it means the federal government has found the drug to be safe and effective for a certain disease or condition. The label information printed in the official prescribing information and in the package insert explains the use for which the FDA has approved the drug. It describes the approved dosage and way the drug should be given (pill, injection, infusion, etc.). In many cases, doctors – based on their knowledge and new information – may prescribe a drug for a use that is not listed in the approved labeling. The use of a drug for a disease that the FDA did not approve it for, or in a dose or by a route not listed on the label, is called "off-label" use of the drug.

Off-label drug use is legal in the United States and in many other countries. But, drugs used off-label are only covered under Part D if the use is cited in one of the reference standards for prescription drugs (called a compendium) named in the new Medicare law. If an off-label use is not listed in one of the approved compendia, Part D does not cover it. And unlike coverage for off-label uses of cancer drugs under Part B, Part D drug plans cannot cover any use not listed.

Why is this important to a cancer patient?

The National Comprehensive Cancer Network estimates that 50% to 75% of all uses of drugs and biologics in cancer care in the US are off label. An older study done by the US General Accounting Office in 1991 found that 1 out of 3 of all drug uses in cancer patients were off label. That same study found that more than half of cancer patients got at least one drug for an off-label use.

Last Medical Review: 10/23/2008
Last Revised: 10/23/2008