A Medicare Advantage plan is not simply Original Medicare with a different insurance card. Medicare Advantage plans are offered by Medicare-approved private companies and provide Part A and Part B benefits through the plan. Most also include Part D drug coverage.

For an expensive clinician-administered medicine, the important distinction is that a drug that belongs in the Medicare Part B pathway can still require plan-specific navigation when the patient is enrolled in Medicare Advantage.

What stays the same?

Medicare says Medicare Advantage plans must cover the medically necessary services that Original Medicare covers. A Part B-type drug does not become a Part D drug simply because a patient chose Medicare Advantage.

What can change?

Original MedicareFederal coverage pathway

Patients generally can use any provider that accepts Medicare. Coverage may depend on national or local Medicare rules and the submitted claim.

Medicare AdvantagePlan-administered pathway

The plan may use provider networks, prior authorization and plan-specific procedures while covering Medicare benefits.

Medicare notes that Medicare Advantage members may need prior authorization before a plan covers certain services or supplies. Networks can also matter: an infusion center that takes Original Medicare is not automatically in-network for every Medicare Advantage plan.

Before an expensive Part B drug is administered
  • Confirm the exact Medicare Advantage plan and network.
  • Ask whether the medicine requires prior authorization or an organization determination.
  • Verify the treatment site is allowed and in-network when required.
  • Confirm the exact product or biosimilar the plan prefers, if the plan has a preference.
  • Check the member's expected cost sharing under the plan.
  • If coverage is denied, use the denial notice and the plan's Medicare appeal instructions.

Part B drug appeals have their own timing

Medicare's current appeal guidance says a standard Medicare Advantage reconsideration involving a Part B drug generally has a 7-day decision timeframe; a fast appeal can have a 72-hour timeframe when the applicable urgency standard is met. The denial notice is the controlling instruction for the actual case.

Do not confuse Part B and Part D

Most Medicare Advantage plans include Part D, but Part D is still a different drug benefit. When a medicine is being infused or injected in a treatment setting, verify whether the exact formulation belongs under Part B before using a Part D formulary as the answer.

Official sources

Medicare.gov — Compare Original Medicare & Medicare Advantage →Medicare.gov — Appeals in Medicare health plans →