Billing for chemo. drugs, Medicare patients

A chemotherapy drug is considered a Part B drug under Original Medicare and Priority Health Medicare plans.

• Chemotherapy drugs obtained in a provider's office or facility are covered whether the provider participates in the patient's plan or not. However, members receive the best benefit if the provider participates with the patient's plan (in-network benefit).
• If the member goes out of plan, he/she should use a Medicare-participating provider to receive the best benefit at this level.

Medicare plan chemotherapy drug benefit

The member benefit for chemotherapy drugs for all Priority Health Medicare plans is as follows:

• From in-network providers: 20%coinsurance (no deductible)
• From out-of-network providers: 20% coinsurance after meeting a $300 deductible

Direct billing

• Providers may collect the 20% coinsurance at time of service or bill the member for it (Medicare Claims Processing Manual, Chapter 1, §30.3.1). 
• Providers may not bill the member or try to collect from the member any additional part of the bill until the provider receives Priority Health's Medicare's Remittance Advice (Medicare Claims Processing Manual, Chapter 1, §30.3.3).

Learn more

Get more details about billing chemotherapy drugs from this document at the Medicare website (document will open in a new browser window).
HON-002, National Coverage Provision on Chemotherapy and Drug Administration