Prescription drugs (outpatient)

Medicare Part B (Medical Insurance)  covers a limited number of outpatient prescription drugs under certain conditions.

Usually, Part B covers drugs you wouldn't typically give to yourself, like those you get at a doctor's office or in a hospital outpatient setting .

Here are some examples of Part B-covered drugs:

  • New Alzheimer’s drug (Leqembi, generic name lecanemab): Medicare covers a new type of medication to slow or delay symptoms of Alzheimer’s. Talk to your provider about whether this drug is right for you.
    • This drug doesn’t cure or reverse Alzheimer’s disease.
    • The drug is given intravenously (through a vein) in a provider’s office or other outpatient setting.
    • If you and your provider decide this treatment is right for you, your provider will submit data as part of an effort to understand how well this new medication works as part of your care. This is part of the process so Medicare will cover the drug. 
  • Drugs used with an item of durable medical equipment (DME): Medicare covers drugs infused through DME (like an infusion pump or nebulizer) if the drug used with the pump is reasonable and necessary.
  • Some antigens: Medicare covers antigens if a doctor or other health care provider prepares them and a properly instructed person (who could be you, the patient) gives them under appropriate supervision.
  • HIV prevention drugs.
  • Injectable osteoporosis drugs.
  • Erythropoiesis-stimulating agents: Medicare covers erythropoietin by injection if you have  End-Stage Renal Disease (ESRD)  or you need this drug to treat anemia related to certain other conditions.
  • Blood clotting factors: If you have hemophilia, Medicare covers injectable clotting factors you give yourself.
  • Injectable and infused drugs: Medicare covers most injectable and infused drugs when a licensed medical provider gives them.
  • Oral End-Stage Renal Disease (ESRD) drugs: Medicare covers some oral ESRD drugs if the same drug comes in an injectable form and the Part B ESRD benefit covers it.

Part B covers calcimimetic medications under the ESRD payment system, including the intravenous medication Parsabiv, and the oral medication Sensipar.

Your ESRD facility is responsible for giving you these medications either at the facility or through a pharmacy they work with. You’ll need to talk to your ESRD facility staff and your health care provider to find out:

  • Where you’ll get these medications
  • How much you’ll pay
  • Parenteral and enteral nutrition (intravenous and tube feeding): Medicare covers certain nutrients if you can’t absorb nutrition through your intestinal tract or take food by mouth.
  • Intravenous Immune Globulin (IVIG): Medicare covers IVIG you get at home if both of these conditions apply:

    • You've been diagnosed with primary immune deficiency disease.
    • Your health care provider decides that it's medically appropriate for you.

    Part B also pays for other items and services related to you getting the IVIG at home.

  • Shots (vaccinations): Medicare covers flu shots, pneumococcal shots and COVID-19 vaccines. Medicare also covers Hepatitis B shots for certain people, and some other vaccines when they’re related directly to the treatment of an injury or illness.
  • Transplant / immunosuppressive drugs. Medicare covers transplant drug therapy if Medicare helped pay for your organ transplant. You must have Part A at the time of the covered transplant, and you must have Part B at the time you get immunosuppressive drugs. 

    If you only have Medicare because of End-Stage Renal Disease (ESRD), your Medicare coverage (including immunosuppressive drug coverage) ends 36 months after a successful kidney transplant. Medicare offers a benefit that helps you pay for your immunosuppressive drugs beyond 36 months if you don’t have certain types of other health coverage (like a group health plan, TRICARE, or Medicaid that covers immunosuppressive drugs). This benefit only covers your immunosuppressive drugs and no other items or services. It isn’t a substitute for full health coverage. If you qualify, you can sign up for this benefit any time after your Part A coverage ends. To sign up, call Social Security at 1-877-465-0355. TTY users can call 1-800-325-0788.
  • Oral cancer drugs: Medicare covers some cancer drugs you take by mouth if the same drug is available in injectable form, or it's a prodrug of the injectable drug. A prodrug is an oral form of a drug that, when ingested, breaks down into the same active ingredient found in the injectable drug. 
  • Oral anti-nausea drugs: Medicare covers oral anti-nausea drugs you get as part of an anti-cancer chemotherapeutic regimen if you take them before, during, or within 48 hours of chemotherapy, or you get them as full therapeutic replacement for an intravenous anti-nausea drug.
  • Self-administered drugs in hospital outpatient settings: Under very limited circumstances, Medicare may pay for some self-administered drugs if you need them for the hospital outpatient services you're getting.

Your costs in Original Medicare

  • Doctors, other health care providers, and pharmacies must accept assignment for Part B-covered drugs, so they should never ask you to pay more than the coinsurance or copayment for the Part B-covered drug itself. 
  • In most cases, after you meet the Part B deductible , you pay up to 20% of the Medicare-approved amount  for covered Part B prescription drugs.
    • Your coinsurance amount can sometimes change depending on your prescription drug's price. 
    • You might pay a lower coinsurance for certain Part B covered drugs and biologicals you get in a doctor's office, pharmacy, or outpatient setting, if their prices have gone up faster than the rate of inflation. The specific drugs and potential savings change every quarter.
  • If the Part B-covered drugs you get in a hospital outpatient setting are part of your outpatient services, you pay a copayment for the services. Part B doesn't cover "self-administered drugs" in a hospital outpatient setting. "Self-administered drugs" are drugs you'd normally take on your own.
  • If you get non-covered prescription drugs in a hospital outpatient setting, you pay 100% of the cost of the drugs, unless you have other drug coverage. If you have other coverage (like Part D), what you pay depends on whether your drug plan covers the drug, and if the hospital is in your plan’s network. Contact your plan to find out what you pay.
  • You pay nothing (and the Part B deductible doesn't apply) for COVID-19 vaccines, or for flu, pneumococcal, and Hepatitis B (for those at intermediate or high risk) shots.
  • For immunosuppressive drugs, you’ll pay a monthly premium of $103 (or higher based on your income) and a $240 deductible in 2024. Once you’ve met the deductible, you’ll pay up to 20% of the Medicare-approved amount for your immunosuppressive drugs. If you sign up for the immunosuppressive drug benefit and have limited income and resources, but don't have full Medicaid coverage, you may qualify for help paying the costs through one of these Medicare Savings Programs: Qualified Medicare Beneficiary (QMB) Program, Specified Low-Income Medicare Beneficiary (SLMB) Program, and Qualifying Individual (QI) Program. Learn about Medicare Savings Programs.

Things to know

Medicare drug plans (Part D) cover many drugs that Part B doesn't cover. If you have Original Medicare, you can join a Medicare drug plan to get Medicare drug coverage. If you join a drug plan, check your plan's drug list (also called a  formulary ) to find out what outpatient drugs it covers.

Part D generally covers all other recommended adult immunizations (like shingles, tetanus, diphtheria, and pertussis vaccines) to prevent illness. Talk to your provider about which ones are right for you. You can now get more vaccines under Part D at no cost to you. Contact your plan for details.

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