Prescription drugs (outpatient)

 

Medicare Part B (Medical Insurance) covers a limited number of outpatient prescription drugs under certain conditions.

Usually, Part B covers drugs you wouldn't typically give to yourself, like those you get at a doctor's office or in a hospital outpatient setting

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Here are some examples of Part B-covered drugs:

 

• Monoclonal antibodies for the treatment of early Alzheimer’s Disease

• Drugs used with some types of durable medical equipment (DME): If the drug used is medically necessary, Medicare covers drugs infused through DME (like an infusion pump or nebulizer).

• Some antigen allergy tests and treatments: Medicare covers antigen tests to check for allergies and their treatment if a doctor or other health care provider prepares them, and they're given by a properly instructed person (who could be you, the patient) under appropriate supervision.

• HIV prevention drugs.

• Injectable osteoporosis drugs.

• Erythropoiesis-stimulating agents: Medicare covers erythropoietin by injection if you have End-Stage Renal Disease (ESRD)  or you need this drug to treat anemia related to certain other conditions.

• Blood clotting factors: If you have hemophilia (a genetic bleeding disorder that keeps your blook from clotting properly), Medicare covers injectable clotting factors you give yourself or get in a doctor's office.

• Injectable and infused drugs: Medicare covers most injectable and infused drugs when a licensed medical provider gives them.

• Oral End-Stage Renal Disease (ESRD) drugs: Medicare covers all oral ESRD drugs.

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Part B covers calcimimetic medications (including the intravenous medication Parsabiv, and the oral medication Sensipar) and phosphate binders.

Your ESRD facility is responsible for giving you these medications either at the facility or through a pharmacy they work with. You’ll need to talk to your ESRD facility staff and your health care provider to find out:

• Where you’ll get these medications

• How much you’ll pay

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• Enteral and parenteral nutrition (intravenous and tube feeding): Medicare covers certain nutrients if you can’t absorb nutrition through your intestinal tract or take food by mouth.

• Intravenous Immune Globulin (IVIG): Medicare covers IVIG you get at home if both of these conditions apply:

  Part B also pays for other items and services related to you getting the IVIG at home.

  • You've been diagnosed with primary immune deficiency disease.

  • Your health care provider decides that it's medically appropriate for you.

• Shots (vaccinations): Medicare covers flu shots, pneumococcal shots and COVID-19 vaccines. Medicare also covers Hepatitis B shots for certain people, and some other vaccines when they're directly related to treating an injury or illness.

• Transplant / immunosuppressive drugs. Medicare covers transplant drug therapy (including certain compounded immunosuppressive drugs) if Medicare helped pay for your organ transplant. You must have Part A at the time of the covered transplant, and you must have Part B at the time you get immunosuppressive drugs. 

   

If you only have Medicare because of End-Stage Renal Disease (ESRD), your Medicare coverage (including immunosuppressive drug coverage) ends 36 months after a successful kidney transplant. Medicare offers a benefit to help you pay for your immunosuppressive drugs beyond 36 months if you don’t have certain types of other health coverage (like a group health plan, TRICARE, or Medicaid that covers immunosuppressive drugs). This benefit only covers your immunosuppressive drugs and no other items or services. It isn’t a substitute for full health coverage. If you qualify, you can sign up for this benefit any time after your Part A coverage ends. To sign up, call Social Security at 1-877-465-0355. TTY users can call 1-800-325-0788.

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• Oral cancer drugs: Medicare covers some cancer drugs you take by mouth if the same drug is available in an injectable form, or it's 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.

• Oral anti-nausea drugs: Medicare covers oral anti-nausea drugs you get as part of a cancer chemotherapeutic regimen if you take them before, during, or within 48 hours of chemotherapy, or you get them as full therapeutic replacement for an intravenous anti-nausea drug.

• Self-administered drugs in hospital outpatient settings: Under very limited circumstances, Medicare may pay for some self-administered drugs if you need them for the hospital outpatient services you're getting.

 

Learn more visit: https://www.medicare.gov/coverage/prescription-drugs-outpatient