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 drugs given by a nebulizer, if the drug used with the pump is reasonable and necessary.
- Some antigens: Medicare covers antigens if a doctor prepares them and a properly instructed person (who could be you, the patient) gives them under appropriate supervision.
- Injectable osteoporosis drugs: Medicare covers injectable osteoporosis drugs if you meet all of these conditions:
- You're a woman with osteoporosis who meets the criteria for the Medicare home health benefit.
- You have a bone fracture that a doctor certifies was related to post-menopausal osteoporosis.
- Your doctor certifies that you can’t give yourself the injection or learn how to give yourself the drug by injection.
In addition, Medicare will cover the home health nurse or aide to provide the injection if your family and/or caregivers are unable or unwilling to give you the drug by injection.
- 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: Medicare covers clotting factors you give yourself by injection, if you have hemophilia.
- Injectable and infused drugs: Medicare covers most injectable and infused drugs when a licensed medical provider gives them, because these types of drugs aren't usually self-administered.
- Oral End-Stage Renal Disease (ESRD) drugs: Medicare covers some oral ESRD drugs if the same drug is available in injectable form and the Part B ESRD benefit covers it.
- 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) provided in home: Medicare covers IVIG if both of these conditions apply:
- You have a diagnosis of primary immune deficiency disease.
- Your doctor decides that it's medically appropriate for you to get the IVIG in your home.
Part B may also cover services (like nursing visits).
- Shots (vaccinations): Medicare covers flu shots, pneumococcal shots, COVID-19 vaccines, 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 paid 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. Keep in mind, Medicare drug coverage (Part D) covers immunosuppressive drugs if Part B doesn't cover them. If you have Original Medicare, you may join a Medicare drug plan to get Medicare drug coverage.
- Oral cancer drugs: Medicare covers some oral cancer drugs you take by mouth if the same drug is available in injectable form or the drug is 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. As new oral cancer drugs become available, Part B may cover them. If Part B doesn’t cover them, Part D does.
- Oral anti-nausea drugs: Medicare covers oral anti-nausea drugs you use as part of an anti-cancer chemotherapeutic regimen if they’re administered before, at, or within 48 hours of chemotherapy or are used as a 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 and pharmacies must accept assignment for Part B-covered drugs, so you should never be asked to pay more than the coinsurance or copayment for the Part B-covered drug itself. Your copay amount can change depending upon your prescription drug's price. In most cases, after you meet the Part B deductible , you pay 0% to 20% of the Medicare-approved amount for covered Part B prescription drugs that you get in a doctor’s office or pharmacy, or in a hospital outpatient setting.
- Your coinsurance can change depending on your prescription drug's price. You might pay a lower coinsurance for certain drugs and biologicals covered by Part B that you get in a doctor's office or pharmacy, or in a hospital outpatient setting, if their prices have increased higher 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 prescription drugs that Part B doesn’t cover in a hospital outpatient setting, you pay 100% for the drugs, unless you have Medicare drug coverage (Part D) or other drug coverage. In that case, 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 if you get drugs in a hospital outpatient setting that Part B doesn’t cover.
- You pay nothing (and the Part B deductible doesn't apply) for flu, pneumococcal, and Hepatitis B shots.
- In 2023, you’ll pay a monthly premium of $97.10* and a $226 deductible if you sign up for the immunosuppressive drug benefit. Once you’ve met the deductible, you’ll pay 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.
* You may pay a higher premium based on your income.
Things to know
Medicare drug coverage (Part D) covers drugs Part B doesn't cover. If you join a Medicare drug plan, check your plan's drug list (also called a formulary ) to see 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.