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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare Part B generally does not pay for drugs that are usually self-administered by the patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-injection. The only exceptions are: 1. blood-clotting factors; 2. drugs used in immunosuppressive therapy; 3. erythropoietin for dialysis patients; 4. osteoporosis drugs for certain homebound patients; 5. certain oral cancer drugs; 6. oral anti-emetics used in certain situations; 7. drugs treated as supplies during an outpatient hospital procedure; and 8. drugs required for the effective use of durable medical equipment. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Benefit Policy Manual, Chapter 15, Sections 50, 50.2, 50.5, and 110.3. Effective January 1, 1998, Medicare also covers self-administered anti-emetics, which are necessary for the administration and absorption of the anti-neoplastic chemotherapeutic agents when a high likelihood of vomiting exists. The anti-emetic drug is covered as a necessary means for administration of the anti-neoplastic chemotherapeutic agents. Oral drugs prescribed for use with the primary drug, which enhance the anti-neoplastic effect of the primary drug or permit the patient to tolerate the primary anti-neoplastic drug in higher doses for longer periods, are not covered. Self-administered anti-emetics to reduce the side effects of nausea and vomiting brought on by the primary drug are not included beyond the administration necessary to achieve drug absorption. Section 1861(s)(2) of the Social Security Act extends coverage to oral anti-emetic drugs that are used as full replacement for intravenous dosage forms of a cancer regimen under the following conditions: a. Coverage is provided only for oral drugs approved by the Food and Drug Administration (FDA) for use as anti-emetics; b. The oral anti-emetic must either be administered by the treating physician or in accordance with a written order from the physician as part of a cancer chemotherapy regimen; c. Oral anti-emetic drugs administered with a particular chemotherapy treatment must be initiated within 2 hours of the administration of the chemotherapeutic agent and may be continued for a period not to exceed 48 hours from that time; d. The oral anti-emetic drugs provided must be used as a full therapeutic replacement for the intravenous anti-
emetic drugs that would have otherwise been administered at the time of the chemotherapy treatment. You can find this information in You can find this information in Medicare Benefit Policy Manual Chapter 15 - Covered Medical and Other Health Services, 50.5.4 - Oral Anti-Nausea (Anti-Emetic) Drugs. (Rev. 185, Issued: 04-15-14, Effective: 05-29-13, Implementation: 07-07-14). An oral antiemetic drug (J8650, J8670, Q0161, Q0162, Q0163, Q0164, Q0166, Q0167, Q0169, Q0173, Q0174, Q0175, Q0177, Q0180, Q0181) is covered if all of the following criteria (1-4) are met: 1. The drug has been approved by the Food and Drug Administration (FDA) for use as an antiemetic, and 2. The drug has been ordered by the treating practitioner as part of a cancer chemotherapy regimen, and 3. The drug is used as a full therapeutic replacement for an intravenous antiemetic drug that would otherwise have been administered at the time of the chemotherapy treatment, and 4. ORAL ANTI-EMETIC drugs administered with a particular chemotherapy treatment must be initiated within two hours of the administration of the chemotherapeutic agent and may be continued for a period not to exceed 48 hours from that time. Criterion 3 is not met when the chemotherapy drug is an oral drug or when the chemotherapy drug is administered intravenously in the home setting because the type and dosage of chemotherapy drugs administered in these situations do not require intravenous antiemetic drugs. If all of the criteria are not met, the oral antiemetic drug will be denied as non-covered. You can find this information in Local Coverage Article: Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) - Policy Article (A52480).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.