4 Medicare Part B Opportunities Pharmacies Shouldn’t Overlook

As the US population ages, a growing number of individuals are becoming Medicare beneficiaries. The most recent data shows that about 67.3 million US adults are enrolled in Medicare coverage, representing about 20% of the population.

For pharmacies, this demographic shift presents an opportunity to diversify services, increase profitability, and become integral to care delivery under Medicare Part B.

Unlocking Growth: 4 Medicare Part B Services Pharmacies Should Explore

Medicare Part B covers a range of clinical services pharmacies are well-positioned to provide after completing the appropriate enrollment steps and meeting regulatory requirements. Below, we highlight four key areas pharmacies can bill for under Medicare Part B, each offering its own path to increased service offerings, patient impact, and reimbursement potential.

1. Drugs & Biologics

Dispensing drugs and specialty pharmaceuticals is already a core function of pharmacies, making this one of the most accessible Medicare Part B opportunities. Aside from immunizations, this is typically the easiest area to integrate operationally.

However, Medicare Part B has strict requirements around medical necessity and documentation. A physician’s prescription alone does not guarantee reimbursement. Pharmacies must consult Local Coverage Determinations (LCDs), which outline:

• Conditions of medical necessity
• Quantity limitations
• Documentation requirements

Training staff on LCD compliance is critical to ensure claim acceptance and proper reimbursement.

2. Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)

Pharmacies interested in billing Medicare for DMEPOS must undergo a more involved process, primarily due to accreditation requirements. After accreditation, pharmacies can apply for Medicare enrollment and expect an additional 90-day processing window.

Key Requirements:

• Pharmacies must be accredited by a CMS-approved Accreditation Organization (unless exempt—see criteria below)
• Policies and procedures must align with accreditation standard
• An onsite survey will be conducted before approval

Accreditation can take several months, as pharmacies must:

• Develop compliant policies and procedures
• Train staff
• Document patient interactions
• Undergo and pass an accreditation survey

A pharmacy may be exempt from DMEPOS accreditation if:

• It’s been enrolled in Medicare for at least five years
• No adverse actions have occurred in the past five years
• DMEPOS billing (excluding drugs and pharmaceuticals) makes up less than 5% of total pharmacy sales

3. Immunizations

More than 12 million vaccines have been administered to nearly 10.3 million Medicare recipients since 2013.

Medical enrollment to provide immunizations is relatively straightforward compared to DMEPOS and specialty medications. Once your pharmacy is authorized to provide immunizations within your state, the next step is to submit the CMS-855B application or enroll through PECOS.

Covered Vaccines under Medicare Part B:

• Influenza
• Pneumonia
• COVID-19
• Hepatitis B (for moderate to high-risk individuals)
• Diphtheria, Tetanus, and Rabies (in specific cases involving injury or exposure)

4. Point-of-Care Testing (POCT)

POCT is one of the fastest-growing services in community pharmacy—particularly after the COVID-19 pandemic accelerated demand for accessible testing. Becoming eligible to bill Medicare Part B for POCT is a two-part process:

1. Obtain a CLIA Certificate of Waiver

• Complete CMS-116 and any required state-specific forms
• Submit your application to your local state agency
• Understand and comply with state-specific regulations, even if federal requirements are minimal

2. Enroll in Medicare

• Submit your application through PECOS or your regional MAC to apply for billing privileges

Once complete, your pharmacy will be positioned to enhance your revenue stream by providing and billing for CLIA-waived tests under Medicare Part B.

Understanding the Medicare Enrollment Process

Your pharmacy must enroll as a Medicare Part B provider or supplier to capitalize on the four Medicare Part B services we highlight in this blog.

Offering services covered under Medicare Part B requires pharmacies to follow a defined, multi-step enrollment process. Pharmacy teams must understand each step to avoid delays, ensure compliance, and successfully gain billing privileges.

1. Determine the Correct Enrollment Application
   Pharmacies usually use forms CMS-855B for services like immunizations and point-of-care testing, and CMS-855S for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) and biologics or specialty medications.
2. Complete the Application
   Your application documentation should include your: business information (legal name, tax ID, address), National Provider Identifier (NPI) and licensure documentation, bank account for electronic funds transfer (EFT), and required supporting documents (e.g., CLIA certificate, accreditation).
3. Submit the Application to Medicare
   You can submit your forms online using PECOS or via paper form through a regional Medicare Administrative Contractor (MAC). Online submissions via PECOS typically process faster.
4. Pay the Application Fee (if required)
   Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers and some other provider types must pay a non-refundable fee. This is done electronically during PECOS submission or by mail for paper applications.
5. Respond to Any Requests for Additional Information
   Medicare may contact you for clarification or missing documents. Prompt responses keep your application moving forward.
6. Receive Your Enrollment Decision
   Approval times can vary but expect up to 90 days for initial enrollment. Upon approval, you’ll receive a decision letter and be assigned a Medicare Provider Transaction Access Number (PTAN).

From selecting the correct application type to preparing documentation and responding to follow-up requests, every phase is critical in securing approval and setting your pharmacy up for long-term success with Medicare.

Turn Opportunity into Action

With the right strategy, pharmacies can successfully expand their scope of services under Medicare Part B. From dispensing biologics and providing durable medical equipment to administering vaccines and offering point-of-care testing, these opportunities can significantly enhance profitability and community impact.

Understanding the application process, documentation requirements, and compliance standards for each area will ensure a smoother path to reimbursement and long-term growth.

Ready to grow your Medicare Part B services? Our medical billing technology connects to Medicare, Medicaid, and hundreds of commercial payors to give your pharmacy the infrastructure to bill confidently, get reimbursed faster, and serve more patients. See our quick reference guide to learn more.