What Drugs Are Covered Under Medicare Part B?

Medicare Part B is a component of Original Medicare, the federal health insurance program for individuals aged 65 or older, younger people with certain disabilities, and people with End-Stage Renal Disease (ESRD). It primarily covers medically necessary services and supplies, including doctors’ services, outpatient care, and some preventive services. While Medicare Part D is the main program for prescription drug coverage, Part B specifically covers a limited set of prescription drugs that are often administered by a healthcare professional in a clinical setting.

Specific Drug Categories Covered

Medicare Part B provides coverage for certain medications typically administered in a doctor’s office, hospital outpatient clinic, or other medical settings. This includes a range of injectable and infused drugs, such as chemotherapy for cancer treatment and certain osteoporosis injections. These drugs are usually not self-administered by the patient.

Oral anti-cancer drugs and oral anti-emetic drugs are also covered by Part B if they are comparable to an injectable drug covered under Part B, ensuring consistency in treatment options. Immunosuppressive drugs for organ transplant recipients are included, especially for those whose Medicare eligibility was due to ESRD, with extended coverage for qualifying individuals. This specialized Part B Immunosuppressive Drug (Part B-ID) benefit solely covers these specific medications.

Certain vaccines are covered under Part B, including the annual flu shot, pneumonia vaccine, and Hepatitis B vaccine for those at medium to high risk, such as individuals with diabetes. COVID-19 vaccines are also covered by Medicare Part B. Additionally, Part B covers vaccines needed after exposure to a harmful virus or bacteria, such as tetanus or rabies shots.

Drugs used with Durable Medical Equipment (DME), like medications for nebulizers, are covered when medically necessary and used with Part B-covered equipment. Blood clotting factors for individuals with hemophilia are also covered, including self-administered doses, recognizing the ongoing need for these treatments. Erythropoiesis-stimulating agents (ESAs) are covered for patients with End-Stage Renal Disease (ESRD) or certain anemia conditions, often when administered by injection. Medicare Part B also covers certain home health agency-administered injectable drugs, such as intravenous immune globulin (IVIG) provided in the home.

How Part B Drug Coverage Works

Drug coverage under Medicare Part B operates under specific conditions. A drug must be medically reasonable and necessary for the diagnosis or treatment of a medical condition for it to be covered. This medical necessity is a foundational requirement for all Part B services, including drug coverage.

Coverage applies when drugs are administered in specific outpatient settings, such as a doctor’s office, a hospital outpatient department, or a skilled nursing facility. In some instances, certain injectable drugs administered in the home by a home health agency may also be covered if they require a Part B-covered infusion pump and home administration is considered reasonable and necessary.

For most Part B-covered drugs, beneficiaries are responsible for the Part B deductible and a 20% coinsurance of the Medicare-approved amount after the deductible is met. However, for specific preventive services like flu, pneumonia, and COVID-19 vaccines, there is no deductible or coinsurance if the provider accepts assignment.

Medicare Part B does not cover most self-administered prescription drugs that individuals pick up at a retail pharmacy. These types of medications are typically covered under a Medicare Part D prescription drug plan.

Finding Information on Your Specific Drug

Determining if a specific medication is covered under Medicare Part B involves steps. A primary resource is your prescribing doctor or pharmacist, as they often have knowledge regarding Medicare coverage for various medications and can provide guidance tailored to your situation. These healthcare professionals can help clarify whether a drug falls under Part B or Part D coverage.

Official Medicare resources also offer information. The Medicare.gov website serves as a central portal for Medicare information, which can provide general guidance on drug coverage. While its primary drug search tool often directs users towards Part D plans for most retail medications, it remains an authoritative source for understanding Medicare benefits.

Beneficiaries can contact Medicare directly by calling the official Medicare helpline. Medicare representatives can provide specific details about whether a drug is covered under Part B and explain any applicable cost-sharing requirements. This direct communication can help resolve complex coverage questions.

After receiving services, reviewing your Explanation of Benefits (EOB) statements from Medicare can provide detailed information on what was covered. For Original Medicare (Parts A and B), beneficiaries receive a Medicare Summary Notice (MSN) quarterly, which summarizes services and coverage details. These documents outline the amount billed, how much Medicare covered, and any remaining out-of-pocket costs.