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:

  • Drugs used with an item of durable medical equipment (DME): Medicare covers drugs infused through DME, like an infusion pump or a nebulizer, if the drug used with the pump is reasonable and necessary.
  • Some antigens: Medicare helps pay for 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 helps pay for 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 helps pay for 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 helps pay for 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 helps pay for some oral ESRD drugs if the same drug is available in injectable form and the Part B ESRD benefit covers it.
Note 

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. They can give them to you at their facility, or through a pharmacy they work with. You’ll need to work with your ESRD facility and your doctor to find out:

  • Where you’ll get these medications
  • How much you’ll pay
  • Parenteral and enteral nutrition (intravenous and tube feeding): Medicare helps pay for 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 helps pay for 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 covers the IVIG itself, but doesn't pay for other items and services related to you getting the IVIG at home.

  • Shots (vaccinations): Medicare covers flu shots, pneumococcal shots, Hepatitis B shots, 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. Medicare Drug Coverage (Part D) usually pays for transplant drugs that Part B doesn't cover. If you have Original Medicare, you may join a Medicare drug plan to get Medicare drug coverage.
    • If you're entitled to Medicare only because of ESRD, your Medicare coverage, including transplant drug therapy, ends 36 months after the month of you kidney transplant. However, beginning January 1, 2023, Medicare will offer a new benefit that helps continue to pay for your immunosuppressive drugs beyond 36 months, if you don’t have other health coverage. Get details about the new program.  
    • If you’re entitled to Medicare because of your age or disability, Medicare will continue to pay for your transplant drugs with no time limit as long as either Medicare paid for your transplant, or your private insurance paid for your transplant (and that insurance was the primary payer ahead of your Medicare Part A (Hospital Insurance coverage) .
    • 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 cancer drugs: Medicare helps pay for 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 helps pay for 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: 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.  In most cases, after you meet the

Part B Deductible

, you pay 20% of the 

Medicare-Approved Amount

 for Part B-covered prescription drugs that you get in a doctor’s office or pharmacy. In a hospital outpatient setting, you pay a copayment of 20%. If your hospital is participating in a certain outpatient drug discount program (called “340B”), your copayment will be 20% of the lower price, with some exceptions. 

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.

Note:

To find out how much your test, item, or service will cost, talk to your doctor or health care provider. The specific amount you’ll owe may depend on several things, like:

  • Other insurance you may have
  • How much your doctor charges
  • If your doctor accepts assignment
  • The type of facility
  • Where you get your test, item, or service

 

Things to know

Medicare drug coverage (Part D) covers drugs Part B doesn't cover. If you have drug coverage, check your plan's drug list (also called a  formulary ) to see what outpatient drugs it covers.