May 2019: How does Medicare Pay for Prescription Medication?

Part B and Part D Prescription Drug Coverage

Part A covers the drugs you need during a Medicare-covered stay in a hospital or a skilled nursing facility (SNF).

Part B covers most drugs administered by your doctor or at a dialysis facility, but the provider or the facility must buy and supply the drugs. Part B also covers some outpatient prescription drugs, mainly certain oral cancer drugs (chemotherapy). Outpatient drugs previously paid for by Part B will continue to be paid for by Part B. Part D cannot pay for any of your drugs that are covered by Part B.

Part D covers most outpatient prescription drugs (drugs you fill at the pharmacy). Check your plan’s list of covered drugs (known as a formulary) to find out whether it covers the drugs that you need.

What should I do if I am having trouble accessing my medication?

Know how your medication is covered. Call 1-800-MEDICARE to find out whether your drug should be covered by Part A, B, or D.

Ask your pharmacist or provider to submit claims to the correct part of Medicare. If your pharmacist is having trouble billing Medicare/your Part D plan, or if you are being denied coverage for a drug, it is possible that the medication is being billed incorrectly. If your provider is unsure of how to submit these claims, tell them they can reach out to your plan or Medicare for assistance.

If this is a Part D-covered drug, they should call your Part D plan.

If this is a Part B-covered drug and you have a Medicare Advantage Plan, they should call your Medicare Advantage Plan.

If this is a Part B-covered drug and you have Original Medicare, they should reach out to the Medicare Administrative Contractor for your region.

If payment is denied, appeal the denial. You have a right to appeal Medicare’s or your plan’s denial. Ask your doctor to help you prove that the mediation is medically necessary for you and that you meet the coverage criteria.

What are some drugs that might be covered by Medicare Part B or Part D?

There are several drugs that may be covered by Part B or Part D, depending on what they are used for and how or where they are administered. Some of these drugs include:

Injectable drugs

• Part B covers injectable drugs if you usually cannot administer the drug yourself and your doctor provides the drug and administers it to you.
• Part D generally covers injectable drugs that you buy at the pharmacy, whether a doctor administers the drug or you administer it yourself.

Vaccines

• Part B covers certain vaccines—influenza (flu) shots, pneumonia shots, and hepatitis B shots for people who are at high risk of contracting hepatitis B. Part B also covers vaccines after you have been exposed to a dangerous virus or disease, such as tetanus.
• Part D covers most vaccines that your doctor recommends you get.

Insulin

• Part B may cover insulin that you use with an insulin pump. Insulin pumps, related supplies, and the insulin used with these pumps are covered as durable medical equipment (DME) if you meet Medicare’s coverage criteria.
• Part D covers insulin and related medical supplies used to inject insulin (syringes, gauze, and alcohol swabs) if you self-inject insulin.

Immunosuppressants

• Part B covers your immunosuppressants if you received your transplant in a Medicare-approved facility and you had Medicare Part A at the time of your transplant.
• Part D covers immunosuppressants if you did not have Medicare Part A at the time of your transplant or you did not have your transplant in a Medicare-approved facility.