Prescription Drugs (outpatient) Coverage by Medicare

Medicare Part B (Medical Insurance) covers a limited number of outpatient prescription drugs under limited conditions. Usually, drugs covered under Part B are drugs that patients will get at a doctor’s office or hospital outpatient setting.

The patient will pay 20% of the Medicare-approved amount for covered Part B prescription drugs that they get in a doctor’s office or pharmacy, and the Part B deductible applies. In a hospital outpatient setting, the patient will pay a copayment of 20%. If your hospital is participating in a certain outpatient drug discount program (called “340B”), your copayment will be 20% of the lower price, with some exceptions.

Medicare Part B Coverage

  • Drugs used with an item of durable medical equipment (DME):
    Medicare covers drugs infused through DME, like an infusion pump or a nebulizer.
  • Some antigens:
    Medicare helps pay for antigens if they’re prepared by a doctor and are given by a properly instructed person (the patient) under appropriate supervision.
  • Injectable osteoporosis drugs:
    Medicare helps pay for an injectable drug if patient is a woman with osteoporosis who meets the criteria for the Medicare home health benefit and has a bone fracture that a doctor certifies was related to post-menopausal osteoporosis. A doctor must certify that the patient can’t give yourself the 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 you the drug by injection.
  • Erythropoiesis-stimulating agents:
    Medicare helps pay for erythropoietin by injection if patients have End-Stage Renal Disease (ESRD)  or they need this drug to treat anemia related to certain other conditions.
  • Blood clotting factors:
    Medicare helps pay for clotting factors patients give themselves by injection if they have hemophilia.
  • Injectable and infused drugs:
    Medicare covers most of these when 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 the drug is covered under the Part B ESRD benefit.
  • Parental and enternal nutrition (intravenous and tube feeding):
    Medicare helps pay for certain nutrients if patient can’t absorb nutrition through your intestinal tract or take food by mouth.
  • Intravenous Immune Globulin (IVIG) provided in-home:
    Medicare helps pay for IVIG if patient have a diagnosis of primary immune deficiency disease. A doctor must decide that it’s medically appropriate for the IVIG to be given in your home. Part B covers the IVIG itself. But, Part B doesn’t pay for other items and services related getting the IVIG at home.
  • Shots (vaccinations):
    Medicare covers flu shots, pneumococcal shots, Hepatitis B shots, and some other vaccines when they’re related directly to the treatment of an injury of illness.
  • Transplant /immunosuppressive drugs:
    Medicare covers transplant drug therapy if Medicare helped pay for the patient’s organ transplant. Medicare won’t pay for any services or items, including transplant drugs, for patients who aren’t entitled to Medicare.

Medicare Part D Coverage

Part D may cover other transplant drugs that Part B doesn’t cover, even if Medicare didn’t pay for the transplant. If patient have ESRD and Original Medicare, generally they will join a Medicare drug plan. If patients entitled to Medicare only because of ESRD, Medicare coverage ends 36 months after the month of the transplant.

  • Oral cancer drugs:
    Medicare helps pay for some oral cancer drugs that are taken by mouth if the same drug is available in injectable form or the drug 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 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 if they’re administered before, at, or within 48 hours of chemotherapy or are used as a full therapeutic replacement for an intravenous anti-nausea drug.
  • Self-administered drugs in hospital outpatient savings:
    Medicare may pay for some self-administered drugs, like drugs given through an IV. Medicare pays for these drugs if patients need them for hospital outpatient services.

Medicare will pay for transplant drugs with no time limit if patient were already entitled to Medicare because of age or disability before they got ESRD or patient became entitled to Medicare because of age or disability after getting a transplant that was paid for by Medicare or private insurance that paid primary to Medicare Part A (Hospital Insurance) coverage, in a Medicare-certified facility.

Keeping track of constant changes to drug-related CMS regulations is an ongoing challenge, resulting in both compliance and reimbursement being at risk. Medical Billers and Coders (MBC) has a well-trained pharmacy billing team who keeps a close eye on insurance coverage by various carriers like Medicare or commercial. carriers. To know more about pharmacy billing services you contact us at 888-357-3226/