Review of Sources for Medicare Covered Drugs and Biologicals

20.5.2 - Review of Sources for Medicare Covered Drugs and Biologicals (Rev. 397, Issued: 12-16-04, Effective: 01-01-05, Implementation: 01-03-05) A/B MACs (B) check updates for Medicare covered services or procedures for new codes or code description changes before updating files. For new codes, the A/B MAC (B) Medical Staff determines coverage in accordance with the coverage rules in Chapter 15 of the Medicare Benefit Policy Manual. A/B MACs (B) refer to common sources for drug pricing information. Examples are the various Redbook products, “Drug Facts and Comparisons,” the FDA publication Approved Drug Products with Therapeutic Equivalence (the Orange Book), or the “Hospital Formulary Pricing Guide” by MediSpan, Inc. If a price cannot be located in the available sources, they contact the manufacturer of the drug. If a code has a description change, A/B MACs (B) adjust formulas to account for any changes in the strength or dosage of the drug. For example, if a code is listed as 50 mg, and changed to100 mg. the drug payment allowance limit is adjusted to compensate for the difference in the dosage.