Does Medicare Part B Cover Prescriptions?

Medicare Part B is a component of Original Medicare, primarily designed to cover medically necessary services such as doctor’s visits, outpatient care, medical supplies, and preventive services. While Part B addresses a range of healthcare needs, its coverage for prescription drugs is generally limited. Understanding the distinct roles of different Medicare parts is important for managing healthcare costs, especially concerning medications.

General Prescription Coverage Under Medicare Part B

Medicare Part B generally does not cover most outpatient prescription drugs that individuals typically pick up from a pharmacy. This part of Medicare focuses on medical services and supplies provided by healthcare professionals in outpatient settings, rather than retail medications. For instance, Part B covers services like doctor’s office visits, ambulance services, and durable medical equipment, which are distinct from the daily or routine prescription drugs used at home.

How Medicare Part D Covers Prescriptions

Medicare Part D serves as the primary avenue for prescription drug coverage within the Medicare program. This coverage is not automatically included with Original Medicare Part A and Part B; instead, it is offered through private insurance companies that are approved by Medicare. Beneficiaries can obtain Part D coverage in two main ways: either through a standalone Prescription Drug Plan (PDP) or as part of a Medicare Advantage Plan (Part C) that includes drug coverage, often referred to as an MA-PD.

Each Part D plan utilizes a formulary, which is a list of covered prescription drugs. These formularies categorize drugs into different tiers, with drugs in lower tiers generally costing less than those in higher tiers. Plans must cover a range of medications across various therapeutic categories, but the specific drugs and their placement on tiers can vary among plans. It is advisable for individuals to check if their specific medications are on a plan’s formulary and at what cost-sharing level.

Beneficiaries typically pay a monthly premium for Part D coverage, which varies by plan and insurer. Many plans also feature an annual deductible, which is the amount an individual must pay out-of-pocket for covered prescriptions before their plan begins to pay. For 2025, the maximum deductible for a Part D plan is $590, though some plans may offer a lower or no deductible. After meeting the deductible, individuals enter the initial coverage period, where they pay a copayment or coinsurance for their medications, and the plan covers the remaining cost.

Beyond the initial coverage period, Part D plans previously included a “coverage gap,” often called the “donut hole,” where beneficiaries paid a higher percentage of drug costs. However, starting January 1, 2025, the coverage gap is eliminated. Once a beneficiary’s out-of-pocket spending on covered drugs reaches a certain threshold, which is $2,000 in 2025, they enter the catastrophic coverage phase. In this phase, Medicare covers all drug costs for the remainder of the year, providing significant financial protection against high prescription expenses.

Specific Situations Where Medicare Part B Covers Medications

While Medicare Part D handles most retail prescriptions, Medicare Part B does cover certain medications under specific, limited circumstances. These typically involve drugs administered by a healthcare professional in a clinical setting, or those used with durable medical equipment. Generally, Part B covers drugs that are not usually self-administered.

One common category is drugs administered in a doctor’s office or hospital outpatient setting, such as injections and infusions. This includes many cancer chemotherapy drugs and certain anti-nausea medications given in conjunction with chemotherapy. Part B also covers specific injectable drugs like those for osteoporosis.

Certain vaccines are also covered by Part B, including flu shots, pneumococcal shots, and Hepatitis B shots for individuals at medium or high risk. The COVID-19 vaccine is also covered under Part B. Additionally, Part B covers drugs used with durable medical equipment (DME), such as nebulizer medications and insulin used with external insulin pumps. For insulin used with a Part B-covered pump, the monthly cost cannot exceed $35 for a month’s supply.

Immunosuppressive drugs for organ transplant recipients are covered by Part B, provided Medicare helped pay for the transplant and the individual has Part A at the time of transplant and Part B when receiving the drugs.

Part B also covers certain oral anti-cancer drugs if the same drug is available in an injectable form, and oral anti-emetic drugs used with chemotherapy. Erythropoiesis-stimulating agents (ESAs), such as epoetin alfa, are also covered by Part B for specific conditions like anemia related to End-Stage Renal Disease or certain cancers.