Prescription drugs on an outpatient basis for those with Medicare
Medicare Part B, also referred to as Part B Medical, covers a limited number of outpatient prescription drugs, and under limited conditions. Typically, these are drugs you would not usually give to yourself, such as what you get at a doctor’s office or out-patient clinic.
Out-patient prescription drugs covered by Part B include:
Infused drugs: Medicare covers drugs infused such as an infusion pump or nebulizer.
Some antigens: Medicare helps pay for antigens prepared by a provider and given by a properly-trained person (who could be the patient) under appropriate medical supervision.
Osteoporosis Drugs: injectable drugs for women with osteoporosis who meet the necessary criteria for the Medicare home health benefit and have a bone fracture that a doctor certifies was related to post-menopausal osteoporosis. A doctor must certify that the woman is unable to learn how to or unable to give herself the drug by injection. The home health nurse won’t be covered to provide the injection unless family members or caregivers are unable or unwilling to provide the drug by injection.
Erythropoisis–stimulating agents: Medicare helps pay for erythropoietin by injection if you have End-Stage Rneal Disease or need this drug to treat anemia related to other conditions.
Blood clotting factors: If you have hemophilia, Medicare helps pay for clotting factors that you give yourself by injection.
Injectable drugs: Medicare covers most injectable drugs given by a licensed medical provider if the drug is considered reasonable and necessary and isn’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 covered under the part B ESRD benefit.
Parenteral and enteral nutrition (intravenous and tube feeding): Medicare helps pay for certain nutrients for people who can’t absorb nutrition through their intestinal tracts or can’t take food by mouth.
Intravenous Immune Globulin (IVIG) provided in the home: 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 does not pay for other items and services related to the patient getting the IVIG in their home.
Hepatitis B shots
Other shots: Medicare helps pay for other vaccines when they’re related to the treatment of an injury or illness (such as tetanus shot after stepping on a nail).
Immunosuppressive drugs: Medicare covers immunosuppressive drug therapy if you received an organ or tissue transplant for which Medicare made payments. (Medicare Part D may cover other immunosuppressive drugs not covered by Part B.
If you’re entitled to Medicare only because of permanent kidney failure, your Medicare coverage will end 36 months after the month of the transplant. Medicare will not pay for any services and items, including immunosuppressive drugs, for patients who are not entitled to Medicare.
Medicare will continue to pay for your immunosuppressive drugs with no time limit if you meet either of the following conditions:
You were already entitled to Medicare because of age or disability before you got End-Stage-Kidney Disease.
You became entitled to Medicare because of age or disability after getting a transplant that was paid for by Medicare, or paid for by private insurance that paid primary to your Part A coverage, in a Medicare-certified facility.
Medicare helps pay for some oral anti-cancer drugs if the same drug is available in injectable form for the same use and covered under Part B. As new oral anti-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. You must take the drugs immediately before, at, or within 48 hours of chemotherapy, and use them as a full treatment replacement for intravenous anti-nausea drugs you would otherwise take.
Medicare may pay for some self-administered drugs, like drugs given through an IV, if you need them for the hospital outpatient services you’re getting.
Your costs with Original Medicare:
For Part B prescription drugs you obtain in a doctor’s office or pharmacy, you pay 20% of the Medicare approved amount. A medigap or medicare supplemental insurance plan will pick up the 20%. Copays and co-insurance can be much more costly with an advantage plan, which replaces your original medicare and limits you to select providers.
For Part B prescription drugs you obtain in a hospital outpatient setting, you pay a copayment. If you get drugs not covered under Part B in a hospital outpatient setting, you pay 100% for the drugs, unless you have Part D prescription drug coverage. What you pay depends on whether your drug plan covers the drug, and whether the hospital is in your drug plan’s network.