Prescription coverage is one of the things Medicare beneficiaries are most concerned about. With good reason, too, since Medicare didn’t offer outpatient prescription coverage for the first 40 years.
Today, however, things are better due to the advent of the Medicare Part D program in 2006. However, there are a number of medications that do fall under ordinary Original Medicare.
Medicare Parts A and B cover certain prescriptions that are administered either in an inpatient hospital setting or by your doctor in a clinical setting. This includes injectable or infusion medications that a doctor must administer to you.
Outpatient medications, on the other hand, are covered under Medicare Part D, which is a voluntary prescription drug program. You’ll have the opportunity to enroll in a Part D drug plan during your initial enrollment period for Medicare.
Let’s look at which medications are covered under each part and what some of the rules and requirements are for getting these medications covered.
Medicare Part A Prescription Requirements
Part A covers your inpatient hospital stays. During an inpatient stay, Medicare Part A will generally cover any medications that are given to you as part of your overall treatment in the hospital. So, for example, anesthesia medication administered during a surgery will be paid for by Part A.
The main requirement here is that the drugs are being given while you are admitted as an inpatient.
Part A has a deductible, which in 2019, is $1364 per benefit period. When you enter the hospital a benefit period begins and that period ends once you have been discharged from the hospital and remained outside the hospital for at least 60 days.
There are no daily copays for your inpatient hospital stay unless you have a stay that lasts longer than 60 days so you shouldn’t have any other Part A out-of-pocket expenses if your hospital stay is less than 60 days.
Medicare Part B Prescription Requirements
When you attend a doctor’s appointment, your physician or his assistant may need to administer certain medications to you in the office. These medications fall under Part B, which covers your outpatient services.
Part B drugs or biologicals are usually injectable, intravenous or infusion medications that you couldn’t easily administer yourself.
Let’s look at some of drugs that Medicare Part B covers:
Medicare Part B covers one flu shot per flu season and also covers two pneumococcal shots that help to prevent certain types of pneumonia. People at high risk for Hepatitis B can also qualify for a series of hepatitis B vaccinations.
Drugs Supplied through Durable Medical Equipment
Some types of medication are administered through a piece of durable medical equipment, such as an insulin pump or a nebulizer. Medications used with this type of equipment are covered under Part B.
Beneficiaries who have had an organ transplant will need immunosuppressive medications. Part B covers these medications
Oral Cancer Drugs
If you are prescribed an oral cancer drug and that same medication is available in an injectable form, then Part B will cover this. Prodrugs that break down into the same active ingredients as are found in the injectable version of the medication may also be covered by Part B.
Part B will also pay for oral anti-nausea medications when they are being used as part of a regimen of chemotherapy. The requirement is that the drug must be given immediately before, during, or within 48 hours after your chemotherapy session. The medication must be given as a full therapeutic replacement for anti-nausea medication that otherwise would have been given intravenously.
If you need nutrients because you can’t absorb the nutrients in your intestinal tract or you can’t eat the food, then Medicare Part B will cover parental and enteral nutrition that is given intravenously or via tube feeding
Typically these are allergy injections prepared by your doctor and administered by himself or his trained staff. Since these are not normally injections that you can give to yourself, they fall under Part B.
Other Injectable Medications
There are several health conditions in which your providers will administer biologic agents for the purpose of controlling inflammation. For example, rheumatoid arthritis, inflammatory bowel disease and psoriasis are all conditions where your doctor may prescribe an injectable biologic drug.
The benefit, of course, to having medications fall under Medicare Part B is that Part B covers them at 80% after you have first satisfied the small annual Part B deductible. Many beneficiaries have Medigap plans in place that will cover the other 20%, leaving you nothing out-of-pocket after your deductible.
While there are 10 different Medigap plans to choose from, the vast majority of Medicare beneficiaries enroll in Medicare supplement plans F, G, or N. All three of these plans cover the 20% Part B coinsurance. Beneficiaries enrolled in Plan N, however, are responsible for excess charges if their doctor is a non-participating Medicare doctor.
Medicare Part B Prescription Rules
The main rule when it comes to Part B drugs is that someone else is administering them to you. If you administer a medication to yourself, even in an outpatient or hospital observation setting, then those drugs will usually fall under Part D.
Knowing this may help you to see why it’s important to enroll in Medicare Part D if you have no other drug coverage, even if you don’t currently take any medications. You never know when you’ll need a new prescription and you can only join Part D plans at certain times of year.
Medicare Part D Prescription Rules
Part D is an entire program that was designed to help Medicare beneficiaries afford outpatient medications. Although the program is voluntary, Medicare will penalize you for late enrollment if you fail to enroll when you are first eligible and have no other creditable coverage.
For a drug to be covered by Part D, it must meet the following conditions:
- Not covered under Medicare Part A or B
- Approved by the Food and Drug Administration
- Only available with a prescription
- Used and sold here in the United States
- Must be used for a medically accepted reason
- Must appear on your plan’s Part D formulary or you must obtain approval via the drug exceptions process.
Despite these rules, the Part D program covers a vast array of medications and there are a number of drugs that Medicare requires all Part D plans to include in their formularies. This includes anti-seizure medications, anti-psychotic medications, antidepressants, anticonvulsants, self-administered immunosuppressive drugs and medications to treat HIV or AIDs.
Each Part D plan must also include at least two medications in each therapeutic class. This is so that if you develop a new illness mid-year, there will be covered medications that your doctor can prescribe.
Some types of drugs are not covered under Medicare Part D at all. Some examples would be drugs for weight loss or gain, drugs for relief of colds or coughs, drugs for cosmetic reasons or hair growth and most vitamins and minerals. Part D also does not cover erectile dysfunction medications unless your doctor has prescribed the for FDA-approved treatment of a condition other than erectile dysfunction.
A Word about Medicare Advantage Plans
Some Medicare beneficiaries choose to enroll in a Part C Medicare Advantage plan instead of Original Medicare. Rest assured that if you have one of these plans, they must cover all the same services as Original Medicare.
So, the same drugs that fall under Part B on Original Medicare must be covered by your Medicare Advantage plan. However, your cost-sharing or co-insurance for these medications may vary by plan, so you’ll always want to consult the plans Summary of Benefits to determine how the plan covers Part B drugs and what you’ll be expected to pay as your share.
Many Medicare Advantage plans also include a built-in Part D drug plan. This means that if you take outpatient medications, you should review the plan’s list of covered outpatient medications, called a formulary, before you enroll in the plan.