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)

What's Covered

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.

Was this medicareinformation helpful?

2 Comments So Far. Add Your Wisdom.

Anonymous said 11 months ago

Medicare no longer pays for any drugs while having an outpatient surgical procedure even if admitted for something to do with that procedure. You are kept as an outpatient which is also an advantage for a hospital, as they get higher reimbursement for outpatient as compared to regular admissions or if E.R. admits you. Would sure love to have someone who could do something about could get on this change. We paid $977.00 for the drugs (normal daily meds and procedure drugs used for the procedure) for an angiogram. Outrageous

about 3 years ago

more info about problems dealing with drug coverage. Such as moving out of a service area and being denied coverage.


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