Your Medicare Coverage

Is my test, item, or service covered?

Prescription drugs (outpatient)

How often is it covered?

Medicare Part B (Medical Insurance) generally doesn't cover most prescription drugs used at home. But, it does cover a limited number of outpatient prescription drugs under limited conditions. Generally, drugs covered under Part B are drugs you wouldn't usually give to yourself. These include drugs you get at a doctor's office or hospital outpatient setting.

Drugs that aren't covered under Part B may be covered under Medicare prescription drug coverage (Part D). If you have Part D, check your plan's formulary to see what outpatient drugs are covered.

Examples of drugs Part B covers:

Medicare helps pay for antigens if both of these apply:

  • They're prepared by a doctor
  • They're given by a properly instructed person (who could be the patient) under appropriate supervision

Medicare helps pay for an injectable drug for women with osteoporosis if both of these apply:

    • The woman meets the criteria for the Medicare home health benefit
    • The woman has a bone fracture that a doctor certifies was related to post-menopausal osteoporosis

A doctor must certify that the woman isn't able to do one of these:

    • Give herself the drug by injection
    • Learn how to give herself the drug by injection

The home health nurse or aide won't be covered to provide the injection unless one of these applies:

  • Family and/or caregivers are unable to give the woman the drug by injection
  • Family and/or caregivers are unwilling to give the woman the drug by injection

Medicare helps pay for erythropoietin by injection if one of these applies:

If you have hemophilia, Medicare helps pay for clotting factors you give yourself by injection.

Medicare covers most injectable and infused drugs given by a licensed medical provider.

Medicare helps pay for some oral ESRD drugs if both of these apply:

  • The same drug is available in injectable form
  • 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 will be 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

Medicare helps pay for certain nutrients for people who can't do one of these:

  • Absorb nutrition through their intestinal tracts
  • Take food by mouth

Medicare helps pay for IVIG for people with a diagnosis of primary immune deficiency disease. A doctor must decide that it's medically appropriate for the IVIG to be given in the patient's home. Part B covers the IVIG itself. But, Part B doesn't pay for other items and services related to the patient getting the IVIG at home.

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 meet either of these conditions:

  • You were already entitled to Medicare because of age or disability before you got ESRD.
  • You became entitled to Medicare because of age or disability after getting a transplant that was paid for by one of these:
Note

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.

Medicare helps pay for some oral cancer drugs you take by mouth if one of these applies:

    • The same drug is available in injectable form.
    • 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.

Medicare helps pay for oral anti-nausea drugs used as part of an anti-cancer chemotherapeutic regimen. The drugs must meet both of these conditions:

  • Be administered immediately before, at, or within 48 hours after chemotherapy
  • Be used as a full therapeutic replacement for an intravenous anti-nausea drugs

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.

Who's eligible?

All people with Part B are covered under limited conditions.

Your costs in Original Medicare

You pay 20% of the Medicare-approved amount, and the Part B deductible applies. The doctor's office or pharmacy must accept assignment for Part B drugs. So, you should never be asked to pay more than the coinsurance or copayment for the drug itself.

You pay 100% for the drugs unless you have Part D or other prescription drug coverage. What you pay depends on both of these:

  • Whether your drug plan covers the drug
  • Whether the hospital is in your drug plan's network

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

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