Medicare Coverage of Kidney Dialysis Drugs
What It Is
Drugs used in connection with kidney dialysis
Medicare Part A covers any drugs provided in connection with kidney dialysis for someone who is a hospital or skilled-nursing-facility inpatient.
Medicare Part B covers two different categories of drugs related to kidney dialysis, provided on an outpatient basis at a dialysis facility or in a patient's home. The first category is made up of drugs for the dialysis itself, including heparin and the antidote to heparin, as well as topical anesthetics. The other category of drugs is made up of agents to help stimulate red blood cell production to treat anemia in patients with end-stage renal disease.
If you have a Medicare Part C Medicare Advantage plan: Medicare Part C Medicare Advantage plans, also called Medicare Advantage plans, must cover everything that's included in original Medicare Part A and Part B coverage. But sometimes a Part C plan covers more, with extra services or an expanded amount of coverage. (Co-payments for Part C plans may also be different than those for Part A or Part B.) To find out whether your plan provides extra coverage or requires different co-payments for kidney dialysis drugs, contact the plan directly.
What Medicare Pays
If dialysis drugs are received by an inpatient, their cost is part of the overall hospital or nursing-facility charges paid by Medicare Part A, subject to the hospital deductible and coinsurance amounts.
If dialysis-related drugs are received on an outpatient basis, either at a dialysis facility or at home, Medicare Part B pays 80 percent of the Medicare-approved amount for those drugs. (If the drugs are part of treatment at a dialysis facility, the drugs are included within the cost of dialysis, for which Medicare Part B pays 80 percent of the Medicare-approved amount.)
Important: Regardless of the rules regarding any particular type of care, in order for Medicare Part A, Medicare Part B, or a Medicare Part C plan to provide coverage, the care must meet two basic requirements:
The care must be "medically necessary." This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or a Medicare Part C plan) agrees that the care is necessary and proper. For help getting your care covered, see FAQ: How Can I Increase the Odds That Medicare Will Cover My Medical Service?
The care must be performed or delivered by a healthcare provider who participates in Medicare.