Does Medicare Part B Pay for Prescriptions?

Medicare’s prescription drug coverage can be complex for beneficiaries. Understanding which part of Medicare covers specific medications is important, as coverage varies based on the drug type, administration, and location. The program is structured into different parts, each designed to cover distinct healthcare services, and this segmentation extends to how prescription drugs are addressed. Navigating these distinctions is important for individuals to anticipate their costs and ensure their medication needs are met.

Medicare Part B Prescription Coverage

Medicare Part B, which primarily covers outpatient medical services, generally provides limited coverage for prescription drugs. It does not cover most outpatient prescription medications picked up from a pharmacy for self-administration. Instead, Part B covers certain drugs administered by a healthcare professional in a clinic, hospital outpatient setting, or at home under specific conditions.

This coverage applies to injectable or infusible drugs that are not typically self-administered. Examples include chemotherapy medications, some osteoporosis drugs, and certain immunosuppressant drugs for individuals who received an organ transplant covered by Medicare. Additionally, Part B covers drugs used with durable medical equipment (DME), such as those administered through nebulizers or infusion pumps.

Specific vaccines are also covered under Part B, including influenza (flu) shots, pneumonia shots, and Hepatitis B shots for those at medium or high risk. Other covered medications can include certain oral anti-cancer drugs if their injectable forms are covered by Part B, and drugs for End-Stage Renal Disease (ESRD), such as erythropoietin and oral ESRD drugs. For any drug to be covered by Part B, it must be medically necessary for diagnosis or treatment. After meeting the annual Part B deductible, which is $257 in 2025, individuals typically pay 20% of the Medicare-approved amount for these covered drugs.

Medicare Part D and Outpatient Prescriptions

Medicare Part D serves as the primary source for most outpatient prescription drug coverage, distinguishing it from the limited drug coverage offered by Part B. These plans are offered through private insurance companies that are approved by Medicare. Individuals can obtain Part D coverage either through a stand-alone Prescription Drug Plan (PDP) or as part of a Medicare Advantage Plan (Part C) that includes drug coverage, known as an MA-PD plan.

Each Part D plan utilizes a formulary, which is a list of prescription drugs covered by the plan. These drugs are typically organized into different tiers, with lower tiers generally having lower out-of-pocket costs, such as for generic medications, while higher tiers include more expensive brand-name or specialty drugs. Plans must cover at least two drugs in most drug categories and must cover all drugs in certain categories like HIV/AIDS treatments and anticancer drugs.

Part D coverage generally progresses through distinct stages throughout the year. The first is the deductible stage, where individuals pay the full cost of their prescriptions until a specified amount is met; in 2025, the maximum deductible is $590. After the deductible (if applicable), the initial coverage stage begins, where the plan pays a portion of the drug costs, and the individual pays a copayment or coinsurance. For 2025, once an individual’s out-of-pocket spending on covered drugs reaches $2,000, they enter the catastrophic coverage stage, where they pay nothing for covered Part D drugs for the remainder of the calendar year, as the coverage gap, or “donut hole,” has been eliminated.

Other Medicare Parts and Prescriptions

Beyond Part B and Part D, other components of Medicare also play a role in prescription drug coverage, albeit in different contexts. Medicare Part A, which primarily covers hospital insurance, includes prescription drugs administered during an inpatient hospital stay or a stay in a skilled nursing facility. These medications are considered part of the overall inpatient care and are typically not billed separately to the patient. Part A also covers drugs that are medically necessary for symptom control or pain relief under the Medicare hospice benefit.

Medicare Part C, known as Medicare Advantage, offers an alternative way to receive Medicare benefits. These plans are provided by private companies approved by Medicare and bundle Part A and Part B coverage, with most also including prescription drug coverage (Part D). If an individual enrolls in a Medicare Advantage Plan that includes drug coverage (MA-PD), their prescription drug benefits come through that single plan, rather than needing a separate stand-alone Part D plan.