Outpatient Prescription Drugs
Medicare Part B (Medical Insurance) covers a limited number of outpatient prescription drugs under limited conditions pertaining to drugs you wouldn’t normally self-administer such as those you receive in a doctor’s office or hospital outpatient setting.
Examples of outpatient prescription drugs covered under Part B are the following:
- Drugs requiring durable medical equipment (DME) for use. Medicare covers drugs infused through DME, like an infusion pump or 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 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 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.
- Parental and internal 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 or 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.
- 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 settings: 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.
What are my costs?
You pay 20% of the Medicare-approved amount for outpatient prescription drugs covered under Part B including the Part B deductible. In a hospital outpatient setting, you pay a copayment of 20%. If your hospital is participating in a “340B” outpatient drug discount program, 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 pay more than the coinsurance or copayment for the Part B drug itself.
You pay 100% for prescription drugs, not covered by Part B, that you receive in a hospital outpatient setting unless you are enrolled in a Part D plan or other prescription drug coverage. With Part D your cost 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 your cost for prescription drugs you receive in a hospital outpatient setting not covered under Part B. You can reference your Part D plan’s formulary to see what outpatient drugs are covered.