Your Medicare Coverage

Is my test, item, or service covered?

Prescription drugs (outpatient) limited coverage

How often is it covered?

Medicare Part B (Medical Insurance) covers a limited number of outpatient prescription drugs, and only under limited conditions. Generally, these are drugs you wouldn't usually give to yourself, such as what you get at a doctor's office or hospital outpatient setting.

Outpatient prescription drugs covered by Part B include:

  • Infused drugs: Medicare covers drugs infused through an item of durable medical equipment, such as an infusion pump or nebulizer.
  • Some antigens: Medicare helps pay for antigens prepared by a provider and given by a properly-instructed person (who could be the patient) under appropriate doctor supervision.
  • Osteoporosis drugs: An injectable drug for women with osteoporosis who meet the criteria for the Medicare home health benefit and have a bone fracture that a doctor certifies was related to post-menopausal osteoporosis. A doctor must certify that the woman is unable to learn how to or unable to give herself the drug by injection. The home health nurse or aide won't be covered to provide the injection unless family and/or caregivers are unable or unwilling to give the woman the drug by injection.
  • Erythropoisis–stimulating agents: Medicare helps pay for erythropoietin by injection if you have End-Stage Renal Disease (ESRD) or need this drug to treat anemia related to certain other conditions.
  • Blood clotting factors: If you have hemophilia, Medicare helps pay for clotting factors you give yourself by injection.
  • Injectable drugs: Medicare covers most injectable drugs given by a licensed medical provider if the drug is considered reasonable and necessary for treatment and isn't usually self-administered.
  • Oral End-Stage Renal Disease (ESRD) drugs: Medicare helps pay for some oral ESRD drugs if the same drug is available in injectable form and covered under the Part B ESRD benefit.
  • Parenteral and enteral nutrition (intravenous and tube feeding): Medicare helps pay for certain nutrients for people who can't absorb nutrition through their intestinal tracts or can't take food by mouth.
  • Intravenous Immune Globulin (IVIG) provided in the home: Medicare helps pay for IVIG for people with a diagnosis of primary immune deficiency disease. A doctor must decide that it's medically appropriate for the IVIG to be given in the patient's home. Part B covers the IVIG itself, but Part B doesn't pay for other items and services related to the patient getting the IVIG in his or her home.
  • Shots (vaccinations):
  • Immunosuppressive drugs: Medicare covers immunosuppressive drug therapy if you received an organ or tissue transplant for which Medicare made payments. (Medicare Part D may cover other immunosuppressive drugs not covered by Part B. Note: If you have ESRD and Original Medicare, you may join a Medicare Prescription Drug Plan.)
    • If you're entitled to Medicare only because of permanent kidney failure, your Medicare coverage will end 36 months after the month of the transplant. Medicare won't pay for any services or items, including immunosuppressive drugs, for patients who aren't entitled to Medicare.
    • Medicare will continue to pay for your immunosuppressive drugs with no time limit if you meet either of the following conditions:
      • You were already entitled to Medicare because of age or disability before you got ESRD.
      • You became entitled to Medicare because of age or disability after getting a transplant that was paid for by Medicare, or paid for by private insurance that paid primary to your Part A coverage, in a Medicare-certified facility.
    Note

    Transplant drugs can be very costly. If you’re worried about paying for them after your Medicare coverage ends, talk to your doctor, nurse, or social worker. There may be other ways to help you pay for these drugs.

  • Oral anti-cancer drugs: Medicare helps pay for some oral anti-cancer drugs if the same drug is available in injectable form for the same use and covered under Part B. As new oral anti-cancer drugs become available, Part B may cover them.
  • Oral anti-nausea drugs: Medicare helps pay for oral anti-nausea drugs used as part of an anti-cancer chemotherapeutic regimen. You must take the drugs immediately before, at, or within 48 hours of chemotherapy, and use them as a full therapeutic replacement for intravenous anti-nausea drugs you would otherwise take.
  • Self-administered drugs in hospital outpatient settings: Medicare may pay for some self-administered drugs, like drugs given through an IV, if you need them for the hospital outpatient services you're getting.

Who's eligible?

All people with Medicare are covered under limited conditions.

Your costs in Original Medicare

  • For covered Part B prescription drugs you get in a doctor’s office or pharmacy, you pay 20% of the Medicare-approved amount. They must accept assignment for Part B drugs, so you should never be asked to pay more than the coinsurance or copayment for the drug itself.
  • For covered Part B prescription drugs you get in a hospital outpatient setting, you pay a copayment. If you get drugs not covered under Part B in a hospital outpatient setting, you pay 100% for the drugs, unless you have Part D or other prescription drug coverage; what you pay depends on whether your drug plan covers the drug, and whether the hospital is in your drug plan’s network.

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