Does Medicare Part B Cover Prescriptions?

Medicare Part B primarily covers medical services, including doctor visits, outpatient care, medical supplies, and preventive services. While it generally does not cover most outpatient prescription drugs picked up at a retail pharmacy, there are specific exceptions for medications administered in clinical settings.

Prescription Drugs Covered by Part B

Medicare Part B covers a select range of prescription drugs, primarily those administered by a medical professional in an outpatient setting, such as a doctor’s office, hospital outpatient department, or dialysis facility. This includes medications that require professional oversight for safe and effective use, such as injectable or infusible drugs.

Many chemotherapy drugs are covered under Part B when administered in a clinic or hospital outpatient setting. This also extends to certain drugs used with durable medical equipment, such as medications delivered through a nebulizer for respiratory conditions.

Part B also covers some oral anti-cancer drugs if they are the oral form of a drug that would be covered under Part B when administered intravenously. Immunosuppressive drugs are covered under specific conditions, such as for organ transplant recipients.

Erythropoiesis-stimulating agents (ESAs) are another category covered by Part B, particularly for individuals with End-Stage Renal Disease (ESRD) or certain types of anemia. Vaccines, such as flu shots, pneumonia shots, and certain Hepatitis B shots, are also covered under Part B. For most Part B covered services, including these drugs, beneficiaries typically pay a 20% coinsurance after meeting their annual Part B deductible.

Prescription Drugs Not Covered by Part B

Medicare Part B generally does not cover most prescription drugs that individuals obtain from a retail pharmacy for self-administration. This includes common maintenance medications prescribed for chronic conditions. These are typically taken orally or self-injected at home.

Over-the-counter (OTC) drugs are also not covered by Medicare Part B, as they do not require a prescription. While some self-injectable drugs might be covered under specific medical conditions and administration requirements, most self-injectable medications fall outside of Part B’s scope. For example, insulin for diabetic patients, unless administered through a durable medical equipment pump, is not covered by Part B.

Part B does not cover drugs used for cosmetic purposes, such as hair growth or anti-aging treatments. Medications for fertility issues are also generally excluded from Part B coverage. These exclusions highlight Part B’s focus on medically necessary services and professionally administered treatments.

Other Medicare Coverage for Prescriptions

For most outpatient prescription drugs not covered by Medicare Part B, coverage is typically available through other parts of the Medicare program. Medicare Part D, also known as Prescription Drug Plans, is the primary way most beneficiaries receive coverage for their retail prescription medications. These are standalone plans offered by private insurance companies that work with Medicare.

Part D plans cover a wide range of prescription drugs, including those for common conditions, and each plan has its own list of covered drugs, known as a formulary. Beneficiaries typically pay a monthly premium, an annual deductible, and then copayments or coinsurance for their prescriptions, with costs varying based on the drug’s tier within the formulary.

Many individuals also receive their prescription drug coverage through Medicare Advantage Plans, often referred to as Part C. These plans are offered by private companies approved by Medicare and bundle Part A (Hospital Insurance), Part B (Medical Insurance), and often Part D (prescription drug coverage) into one comprehensive plan. If a Medicare Advantage plan includes prescription drug coverage, it is known as an MA-PD plan, and all drug benefits come through that single plan.