Medicare Coverage of Out-Patient Injectable Medication
Medicare Part B vs. Part D drug coverage
Your Medicare hospitalization (Part A) and medical (Part B) coverage work differently from your prescription (Part D) coverage. Depending on what a drug is used for and how and where it's used, it might be covered by Parts A or B instead of your prescription coverage (Part D).
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, like those you get at a doctor's office or hospital outpatient setting. Drugs not 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:
- Drugs used with an item of durable medical equipment: Medicare covers drugs infused through an item of durable medical equipment, 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 given by a properly instructed person (who could be the patient) under appropriate supervision.
- Injectable osteoporosis drugs: Medicare helps pay for an injectable drug for women with osteoporosis who meet the 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 or aide won't be covered to provide the injection unless family and/or caregivers are unable or unwilling to give the woman the drug by injection.
- Erythropoisis–stimulating agents: Medicare helps pay for erythropoietin by injection if you have End-Stage Renal Disease (ESRD) or need this drug to treat anemia related to certain other conditions.
- Blood clotting factors: If you have hemophilia, Medicare helps pay for clotting factors that you give yourself by injection.
- Injectable and infused drugs: Medicare covers most injectable and infused drugs 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 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 Part B doesn't pay for other items and services related to the patient getting the IVIG in his or her home.
- Shots (vaccinations):
- Flu shots
- Pneumococcal shots
- Hepatitis B shots
- Other shots: Medicare helps pay for some other vaccines when they're directly related to the treatment of an injury or illness.
- Transplant drugs (also called immunosuppressive drugs): Medicare covers transplant drug therapy if Medicare helped pay for your organ transplant. (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.)
- 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 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 form of the 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. The drugs must be administered immediately before, at, or within 48 hours after chemotherapy, and must be used as a full therapeutic replacement for: an intravenous anti-nausea drugs.
- Self-administered drugs in hospital outpatient settings: 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.
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 won't pay for any services or items, including transplant drugs, for patients who aren't entitled to Medicare.
Medicare will continue to 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 Medicare, or paid for by private insurance that paid primary to your Medicare Part A (Hospital Insurance) coverage, in a Medicare-certified facility.
All people with Part B are covered under limited conditions.
Your costs in Original Medicare
- For covered Part B prescription drugs you get in a doctor’s office or pharmacy, you pay 20% of the Medicare-approved amount, and the Part B deductible applies. They 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.
- For covered Part B prescription drugs you get in a hospital outpatient setting, you pay a copayment. 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; what you pay depends on whether your drug plan covers the drug, and whether the hospital is in your drug plan’s network.