Medicare Coverage of Self-Administered Drugs at a Hospital Outpatient Location
Medicare Part B (Medical Insurance) generally covers care you get in a hospital outpatient setting, like an emergency department, observation unit, surgical center or pain clinic. Part B only covers certain drugs in these settings, like drugs given through an IV (intravenous infusion).
Sometimes people with Medicare need “self-administered drugs” while in hospital outpatient settings. “Self-administered drugs” are medications you would normally take on your own. Part B generally doesn’t pay for self-administered drugs unless they are required for the hospital outpatient services you’re getting. If you get self-administered drugs that aren’t covered by Medicare Part B while in a hospital outpatient setting, the hospital may bill you for the drug. However, if you are enrolled in a Medicare drug plan (Part D), these drugs may be covered.
What you should know about Medicare drug plans (Part D) and self-administered drugs:
- Generally, your Medicare drug plan only covers prescription drugs and won’t pay for over-the-counter drugs, like Tylenol® or Milk-of-Magnesia®.
- Any drug you get needs to be on your Medicare drug plan’s formulary (or covered by an exception).
- You can’t get your self-administered drugs in an outpatient or emergency department setting on a regular basis.
- Your Medicare drug plan will check to see if you could have gotten these self-administered drugs from an in-network pharmacy.
- Since most hospital pharmacies don’t participate in Medicare Part D, you may need to pay up front and out-of-pocket for these drugs and submit the claim to your Medicare drug plan for a refund. Check with your hospital to see if they participate in Part D. If possible, bring any drugs (or a list of drugs you are taking) with you to the hospital and show them to the staff. It helps the hospital staff to know what drugs you take at home.
Common questions and answers about how Medicare drug plans (Part D) cover self-administered drugs and what should you do if you get a bill for self-administered drugs that aren’t covered by Part B in a hospital outpatient setting?
- Follow the instructions in your Medicare drug plan’s enrollment materials on how to submit an out-of-network claim, or call your plan for information about how to submit a claim.
- Your plan will ask you to send certain information, like the emergency room bill that shows what self-administered drugs you were given. You may also need to explain the reason for your hospital visit. Keep copies of any receipts and any paperwork you send your plan.
- Your Medicare drug plan will check to see if the drug is on your Medicare drug plan’s formulary; otherwise, you may need to file an exception.
- Your plan may ask you if you could have reasonably gotten any of the drugs from a participating network pharmacy. For example, if you could have taken a dose of a drug that you got from your network pharmacy before your outpatient hospital appointment, your Medicare drug plan may not pay you back for that drug.
- If the drug is covered by your Medicare drug plan, your plan may only reimburse you the in-network cost for the drug minus any deductibles, copayments, or coinsurance that you would normally be charged for the drug.
What you’ll have to pay for self-administered drugs that aren’t covered by Medicare Part B?
- If the drug is covered by your Medicare drug plan, you may need to pay the difference between what the hospital charged and what the plan paid in addition to any deductibles, copayments, or coinsurance you would normally pay. This amount counts towards your Part D out-of-pocket costs. You must submit the claim to your plan for it to count towards your out-of-pocket costs.
- If the drug isn’t covered by your Medicare drug plan, you need to pay what the hospital charges for the drug. As mentioned previously, you can always request an exception if your plan tells you a drug isn’t on their formulary.