MACs Continue to Use Different Methods to Determine Drug Coverage

Medicare Administrative Contractors (MACs) are responsible for reviewing Part B outpatient drug claims to ensure that Medicare pays for drugs that meet the criteria for coverage. Each MAC determines whether a particular use for a given drug, such as a use not approved by the Food and Drug Administration, is "medically accepted" and therefore, covered in its jurisdiction. If MACs do not have appropriate methods to determine drug coverage, Medicare and its beneficiaries may pay for drug uses that are not medically accepted. Further, beneficiaries' access to drugs may vary based on the coverage criteria set in their jurisdictions. This study reviewed the methods MACs used to make coverage determinations for Part B drugs, as well as their methods for ensuring that claims were paid according to these coverage determinations.