Medicare Coverage of Outpatient Prescription Drugs
What It Is
Prescription drugs, taken by or administered to a patient at home, or administered to a patient in an outpatient setting (doctor's office, clinic, or hospital outpatient department)
For coverage of most prescription drugs taken by a patient at home, the patient must be enrolled in a Medicare Part D prescription drug plan, or in a Medicare Part C Medicare Advantage plan that specifically covers prescription drugs.
Medicare Part B, however, covers most drugs that must be administered by injection, plus other drugs that are not normally self-administered, when provided by a licensed medical provider in a doctor's office, clinic, or hospital outpatient setting.
Medicare Part B also covers a few self-administered prescription drugs, in any outpatient setting. These include: * Infusion drugs, used with durable medical equipment. * Antigens, if administered under doctor supervision. * Osteoporosis drugs (injected), for certain female patients. * Erythropoiesis-stimulating agents (injected) for patients with end-stage renal disease (permanent kidney failure) or certain other anemia conditions. * Blood-clotting factors (injected) for patients with hemophilia. * Immunosuppressive drugs for transplant patients if the transplant was fully or partially covered by Medicare Part A. * Oral cancer drugs (some but not all) if the same drug is available in injectable form. * Oral antinausea drugs as part of a chemotherapy regimen, if administered within 48 hours of chemotherapy and replacing intravenous antinausea drugs.
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 outpatient prescription drugs, contact the plan directly.
What Medicare Pays
Medicare Part B pays nothing for most prescription drugs taken at home.
Medicare pays 100 percent of the cost of covered drugs administered to a patient by a medical provider in an office, clinic, or hospital outpatient department, except for a co-payment or coinsurance amount the patient may be responsible for.
Medicare Part B pays 80 percent of the Medicare-approved amount for covered, self-administered prescription drugs.
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.