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Coverage under Medicare
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The Original Medicare Plan does not cover most prescription drugs. Part B covers a limited number of outpatient prescription drugs. Your pharmacy or doctor must accept assignment on prescription drugs covered under Part B. Part B covers drugs that aren’t usually self-administered when you are given them in a hospital outpatient department or doctor’s office. Generally, Medicare doesn’t cover self-administered drugs you get in an outpatient setting like an emergency room or observation unit. You can get comprehensive drug coverage by joining a Medicare drug plan (also called “Part D”). For more information, please visit the Medicare Prescription Drug Plan Finder on our web site.
The following outpatient prescription drugs are covered:
- Drugs infused through an item of durable medical equipment, such as an infusion pump or nebulizer if considered reasonable and necessary.
- Some Antigens: Medicare will help pay for antigens if they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision.
- Osteoporosis Drugs: Medicare helps pay for an injectable drug for osteoporosis for certain women with Medicare. Please refer to the coverage information under Home Health Care for Women with Osteoporosis.
- Erythropoisis–stimulating Agents (such as Epogen®, Procrit®, Epoetin alfa, or Aranesp®, Darbepoetin alfa): Medicare will help pay for erythropoietin by injection if you have end-stage renal disease (permanent kidney failure) or need this drug to treat anemia related to certain other conditions.
- Blood Clotting Factors: If you have hemophilia, Medicare will help pay for clotting factors you give yourself by injection.
- Injectable Drugs: Medicare covers most injectable drugs administered by a licensed medical practitioner, if the drug is considered reasonable and
necessary for treatment. - Immunosuppressive Drugs: Medicare covers immunosuppressive drug therapy for transplant patients if the transplant was paid for by Medicare (or paid by private insurance that paid as a primary payer to your
Medicare Part A coverage) in a Medicare-certified facility.
Note: Medicare drug plans may cover immunosuppressive drugs, even if Medicare or an employer or union group health plan didn’t pay for the transplant. - Oral Cancer Drugs: Medicare will help pay for some cancer drugs you take by mouth if the same drug is available in injectable form.
Currently, Medicare covers the following cancer drugs you take by mouth:
- Capecitabine (Xeloda®)
- Cyclophosphamide (Cytoxan®)
- Methhotrexate (Rheumatrex®)
- Temozolomide (Temodar®)
- Busulfan (Myleran®)
- Etoposide (VePesid®)
- Melphalan (Alkeran®)
As new cancer drugs become available, Medicare may cover them.
- Oral Anti-Nausea Drugs:Medicare will help pay for oral anti-nausea drugs used as part of an anti-cancer chemotherapeutic regimen. The drugs must be administered within 48 hours and must be used as a full
therapeutic replacement for the intravenous anti-nausea drugs that would otherwise be given.
Medicare also covers some drugs used in infusion pumps and nebulizers if considered reasonable and necessary.
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The amount you need to pay
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You pay 100% for most prescription drugs you take at home, unless you have Part D. You pay coinsurance or a copayment for prescription drugs that you are given when you are in a doctor’s office or hospital outpatient department. You pay 20% of the Medicare-approved amount for covered prescription drugs. Coverage under Part B islimited.
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The part of Medicare that pays for this service or supply
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Part B Benefit
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Medicare Contact for additional information
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State of Hawaii DME MAC -- Durable Medical Equipment Medicare Administrative Contractor: 1-800-633-4227
Jurisdiction D
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Important notes
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- You must pay an annual $135 (in 2009) deductible for Part B services and supplies before Medicare begins to pay its share.
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