Coverage Policy
The information displayed below pertains specifically to the Pharmacy setting of care. For information tailored to the Physician Office setting or Hospital Outpatient setting, please select the appropriate tab to the left. Coding, coverage, and reimbursement may vary significantly by payor, plan, patient, and setting of care. See below
Medicare
In general, Medicare considers subcutaneous injectable medications to be self-administered and, therefore, covered under Part D. However, Medicare covers FRAGMIN® under Part B when administered under a physician’s supervision and under Part D when dispensed for self-administration by a patient or caregiver. When provided as a Part B benefit, claims for FRAGMIN® are billed to contractors such as Fiscal Intermediaries (hospital outpatient setting), carriers (physician office setting) or the new Part A/B Medicare Administrative Contractors (MACs). Part D benefit claims for FRAGMIN® are billed to Part D plan sponsors. Providers should ensure that they are adhering to appropriate local contractor or Part D plan sponsor claim filing requirements when submitting claims for FRAGMIN®.
More information about Medicare Part B
More information about Medicare Part D
Payor Reimbursement
Medicare Part D plan sponsors negotiate payment rates with pharmacies. Therefore, reimbursement for drugs dispensed by pharmacies varies by contract. Payments may or may not include a dispensing fee per fill.
