How Prescription Drugs are Covered

Outpatient prescription drugs are typically not covered under Original Medicare Part A or Medicare Part B. However, there are a few prescriptions drugs, usually injectable drugs and or drugs that you would not administer yourself, which Medicare Part B (also known as Medicare’s medical insurance) may cover. These drugs are typically given in the form of outpatient medical treatments administered in a doctor’s office or while in a skilled nursing facility. Prescription drugs that may be covered by original Medicare Part B include, but are not exclusively limited to, the below categories as of October 19th, 2012. Always check with the Medicare for any changes and to verify coverage.

Medicare Covered Drugs

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 (ERSD) 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):

Flu Shots

Pneumococcal shot

Hepatitis B shots

Other shots: Medicare helps pay for some other vaccines when they’re directly related to the treatment of an injury or illness (like a tetanus shot after stepping on a nail).

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.

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.

Your Cost for Medicare Covered Drugs

It is important to note that copays and/or co-insurance may apply for each drug identified herein and the provider must accept Medicare Part B assignment. Typically, you pay 20% of the Medicare approved amount for prescription drugs that are covered under Medicare Part B. In a hospital outpatient setting, you are responsible for any copayment. However, if you receive drugs in a hospital outpatient setting that are not covered by Medicare Part B; you are responsible for 100% of the cost of the drugs unless you have a Medical approved Prescription Drug Plan (Part D). If you have a Part D plan, then the amount you pay will be determined based whether the drug is on the formulary for your plan, and whether the hospital is in your drug plan’s network.

Disclaimer: If you are ever in doubt regarding coverage of a drug under original Medicare, you or your physician can verify coverage by contacting the Center for Medicare Services at 1-800-MEDICARE. The above information was gathered on October 19, 2012 from the below source. Always check back with Medicare’s Website to find the most current updates and coverage.