Prescription drugs (outpatient)

Prescription drugs (outpatient)

 usually doesn't cover most prescription drugs used at home, but it does cover a limited number of outpatient prescription drugs under limited conditions.

Usually, drugs covered under Part B are drugs you wouldn't usually give to yourself, like those you get at a doctor's office or 

.

Here are some examples of drugs covered by Part B:

  • 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.
  • Some antigens: Medicare helps pay for antigens if they’re prepared by a doctor and are given by a properly instructed person (who could be you, the patient) under appropriate supervision.
  • Injectable osteoporosis drugs: Medicare helps pay for an injectable drug if you’re a woman with osteoporosis who meets the criteria for the Medicare home health benefit and has a bone fracture that a doctor certifies was related to post-menopausal osteoporosis. A doctor must certify that you can’t give yourself the injection or learn how to give yourself 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 you the drug by injection.
  • Erythropoiesis-stimulating agents: Medicare helps pay for erythropoietin by injection if you have  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 of these when given by a licensed medical provider.
  • 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 drug is covered under the Part B ESRD benefit.

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 and how much you’ll pay.

  • Parental and enternal 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 you have a diagnosis of primary immune deficiency disease. A doctor must decide that it's medically appropriate for the IVIG to be given in your home. Part B covers the IVIG itself. But, Part B 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 of illness.
  • Transplant / immunosuppressive drugs. Medicare covers transplant drug therapy if Medicare helped pay for your organ transplant. Medicare won't pay for any services or items, including transplant drugs, for patients who aren't entitled to Medicare.

Part D may cover other transplant drugs that Part B doesn't cover, even if Medicare didn't pay for the transplant. If you have ESRD and Original Medicare, you may join a Medicare drug plan.

If you're entitled to Medicare only because of ESRD, your Medicare coverage ends 36 months after the month of the transplant.

Medicare will pay for your transplant drugs with no time limit if you were already entitled to Medicare because of age or disability before you got ESRD or you became entitled to Medicare because of your age or disability after getting a transplant that was paid for by Medicare or private insurance that paid primary to your 

 coverage, in a Medicare-certified facility.

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.
  • Oral anti-nausea drugs: Medicare helps pay for oral anti-nausea drugs used 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 savings: Medicare may pay for some self-administered drugs, like drugs given through an IV. Medicare pays for these drugs if you need them for the hospital outpatient services you're getting.
How often is it covered?
Your costs in Original Medicare

You pay 20% of the 

 for covered Part B prescription drugs that you get in a doctor’s office or pharmacy, and the Part B 

 applies. 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. Doctors and pharmacies must accept assignment for Part B drugs, so you should never be asked to pay more than the coinsurance or copayment for the Part B drug itself.

If you get drugs that Part B doesn’t cover in a hospital outpatient setting, you pay 100% for the drugs, unless you have Part D or other prescription drug coverage. In that case, what you pay depends on whether your drug plan covers the drug, and whether the hospital is in your drug plan’s network. Contact your prescription drug plan to find out what you pay for drugs you get in a hospital outpatient setting that Part B doesn’t cover.

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
  • Whether your doctor accepts assignment
  • The type of facility
  • Where you get your test, item, or service

 

Things to know

Drugs that aren't covered under Part B may be covered under 

. If you have Part D, check your plan's 

 to see what outpatient drugs are covered.

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