Question:

How does the term “usually” apply to the Medicare drug payment?

Answer:

For the purposes of applying this exclusion, the term “usually” means more than 50 percent of the time for all Medicare beneficiaries who use the drug. Therefore, if a drug is self-administered by more than 50 percent of Medicare beneficiaries, the drug is excluded from coverage and the A/B Medicare Administrative Contractor (MAC), or home health and hospice (HHH) MAC may not make any Medicare payment for it. In arriving at a single determination as to whether a drug is usually self-administered, A/B MACs and (HHH) should make a separate determination for each indication for a drug as to whether it is usually self-administered.

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