Cody Casey
Medicare drug plans (Part D) cover many drugs that Part B does not. If you have Original Medicare, you can opt for a Medicare drug plan to get coverage. The cost of Medicare drug coverage depends on the plan and the type of medication. Some medications are covered by Medicare Part B, which includes outpatient prescription drugs. Medicare Part D generally covers all adult vaccines, and you won't be charged a copayment or deductible for vaccines that the Advisory Committee on Immunization Practices (ACIP) recommends.
| Characteristics | Values |
|---|---|
| Type of insurance | Hospital insurance |
| Who is eligible | US citizens or permanent residents aged 65 or above, or younger people with disabilities |
| Cost | Free for those who have worked 40 quarters and paid Medicare tax; $285 monthly for those who paid Medicare taxes for at least 30 quarters; $518 monthly for those who paid Medicare taxes for fewer than 30 quarters |
| What it covers | Inpatient hospital stays, including in skilled nursing facilities or psychiatric hospitals; some home health services and hospice services; prescription drugs needed during a Medicare-covered stay in a hospital or skilled nursing facility |
| What it does not cover | Doctor fees during a hospital stay; more than 100 days of an inpatient stay in a skilled nursing facility |
| Other information | Individuals may be responsible for around 5% of the Medicare-approved amount for respite care; they may also have to pay a copayment of $5 for each prescription drug |
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What You'll Learn
Medicare Savings Programs
There are four types of Medicare Savings Programs:
- Qualified Medicare Beneficiary (QMB): QMB covers the Medicare Part A premium for people who do not have enough work history to get premium-free Part A. It also pays the Part B premium, deductibles, and coinsurance. People may qualify for QMB if they have an income of less than 100% of the Federal Poverty Level (FPL) and resources under $9,660 if single, or $14,470 if married.
- Specified Low-Income Medicare Beneficiary (SLMB): SLMB pays for the Medicare Part B premium.
- Qualifying Individual (QI): QI pays for the Medicare Part B premium for people who do not qualify for any other Medicaid coverage or benefits.
- Qualified Disabled and Working Individuals (QDWI): QDWI helps pay for a person's Part A premium.
MSPs are available to older adults and younger adults with disabilities who may not qualify for full Medicaid. Enrollment in an MSP can save money on Medicare costs and provide automatic Extra Help with paying for prescription drugs.
To apply for a Medicare Savings Program, you must apply through your state, which determines which program(s) you qualify for. In many cases, to qualify for an MSP, you must have income and resources below a certain limit, although these limits vary by state and go up each year.
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Part D coverage
Medicare Part D is one of the four parts of Medicare, the federal health insurance for those aged 65 or over and younger people with disabilities. Part D covers prescription drugs and additional vaccines that aren't typically covered by Medicare Part B.
There are three phases of Part D coverage, and you will pay a different amount for your prescriptions in each phase. The phases are:
- Deductible period: You pay the full negotiated price for your covered prescription drugs until you meet your Part D deductible. The deductible amount can change every year.
- Initial coverage period: Once you meet your deductible, your plan will help pay for your covered prescription drugs. You will pay a copayment or coinsurance for every prescription you fill. The initial coverage period ends when you have spent a total of $2,000 in out-of-pocket costs within the calendar year.
- Catastrophic coverage: Once you have spent over $2,000 in out-of-pocket costs for covered drugs, you enter the catastrophic coverage phase. During this phase, you pay nothing for your covered Part D drugs.
It is better to enroll in Medicare Part D when you enroll in Original Medicare, as you may have to pay a penalty for late enrollment otherwise.
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Immunosuppressive drugs
Medicare Part A:
Medicare Part A covers immunosuppressive drugs during a hospital stay. This includes anti-rejection drugs for patients who have undergone organ transplants. However, coverage under Part A is typically limited to the length of the hospital stay, and there may be additional out-of-pocket expenses.
Medicare Part B:
Medicare Part B covers immunosuppressive drugs for patients with End-Stage Renal Disease (ESRD) who have undergone a kidney transplant. This coverage is provided for 36 months after the transplant, as long as the procedure was performed at a Medicare-approved facility. After 36 months, Medicare coverage for ESRD patients ends, and they may need to transition to other coverage options. For individuals who qualify for Medicare due to age or disability, Part B will cover immunosuppressive medications for life after an organ transplant, provided certain criteria are met.
Medicare Part B-ID:
Medicare Part B-ID is a specific benefit for patients with ESRD who require continuous immunosuppressive drugs. It covers the cost of these medications after the initial 36 months of Medicare coverage ends. To be eligible for Part B-ID, individuals must not have other health coverage that includes immunosuppressive drug coverage. This benefit only covers immunosuppressive drugs and no other items or services.
Medicare Part C (Medicare Advantage Plans):
Medicare Advantage Plans, also known as Part C, may cover immunosuppressive medications after an organ transplant if certain eligibility requirements of Medicare Parts A and B are met. These plans must cover at least as much as Original Medicare (Part A and Part B). Additionally, if immunosuppressive drugs are used to treat an autoimmune condition, the prescription drug portion of Medicare Advantage Plans with a Part D benefit will cover the cost.
Medicare Part D:
Medicare Part D is prescription drug coverage and is not included in Original Medicare. It covers immunosuppressive drugs, but the specific medications and costs vary from plan to plan. Part D typically results in higher costs and additional restrictions, such as using specific in-network pharmacies.
It is important to note that Medicare coverage for immunosuppressive drugs can be complex, and the specific plan details, eligibility requirements, and costs may vary. Patients should carefully review their Medicare plan and consult with their healthcare provider to understand their coverage for immunosuppressive medications.
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Oral cancer drugs
Cancer treatment can be expensive, but Medicare can help cover some of the costs. Medicare Part B covers cancer drugs administered intravenously or by mouth. If the drug is only available orally, Medicare Part D should cover it. Medicare Part D may cover oral cancer drugs, chemotherapy treatments, and related prescription drugs. Medicare Part B also covers anti-nausea drugs taken orally or intravenously, provided they are administered within 48 hours of cancer treatment.
Medicare Part D is a prescription drug coverage option offered by private insurance companies that can be added to Original Medicare (Part A and Part B) or included in a Medicare Advantage (Part C) plan. It offers beneficiaries access to a wide range of medications, including those used in cancer treatment and managing its side effects. It is important to review the plan's formulary, a list of covered prescription drugs, to ensure that the specific medications you need are covered under your chosen plan.
Medicare Advantage (Part C) plans are private health insurance plans that offer the same benefits as Original Medicare (Part A and Part B). Some plans may offer additional benefits, and different plans have different restrictions on which drugs they will cover. Medicare Advantage plans must still provide at least the same coverage as Original Medicare but may have different rules and costs.
Medicare covers a variety of preventative screenings related to different kinds of cancer, including breast cancer, cervical cancer, prostate cancer, lung cancer, and colorectal cancer. The frequency of these screenings and how they are covered may vary, and coverage may depend on meeting specific conditions. Medicare also covers most of the cost of a second opinion before cancer surgery, and in certain cases, a third opinion if the first and second opinions differ.
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Outpatient prescription drugs
Medicare covers prescription drugs in different ways depending on your care setting and treatment needs. There are two main ways to get Medicare drug coverage:
Medicare Advantage Plan (Part C) or other Medicare health plan with drug coverage
If you are in a Medicare Advantage Plan or other Medicare plan, your plan may have different rules. However, your plan must provide at least the same coverage as Original Medicare. Medicare Part B (Medical Insurance) covers a limited number of outpatient prescription drugs under certain conditions. Part B covers drugs that are typically administered by a healthcare provider or at a dialysis facility, but the provider or facility must buy and supply the drugs. This includes certain oral cancer drugs (chemotherapy), HIV prevention drugs, injectable osteoporosis drugs, and erythropoiesis-stimulating agents for patients with End-Stage Renal Disease (ESRD) or anemia. Part B also covers drugs used with some types of durable medical equipment (DME) when medically necessary, such as infusion pumps or nebulizers.
Medicare Drug Plan (Part D)
Medicare Drug Plan (Part D) is offered by private companies as a stand-alone plan for those enrolled in Original Medicare or as part of a Medicare Advantage Plan. Part D covers most outpatient prescription drugs (drugs filled at a pharmacy). It also covers all adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP), including vaccines for Respiratory Syncytial Virus (RSV), shingles, whooping cough, and measles. Part D does not cover any drugs that are already covered by Part B. If you have Original Medicare, you can join a separate Medicare Drug Plan to get prescription drug coverage. However, you must already have Part A and/or Part B to be eligible for Part D.
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Frequently asked questions
Medicare Part A covers hospital stays, care in skilled nursing facilities, and some home health and hospice care.
Medicare Part A does not typically cover prescription drugs. However, it may cover certain medications administered during a hospital stay or as part of outpatient care in specific circumstances.
Medicare Part B covers some outpatient medications, such as those administered in a doctor's office during a visit. Part B may also cover certain oral cancer drugs if they are related to injectable treatments.
There are several ways to reduce the cost of prescription drugs with Medicare:
- Enrolling in a Medicare drug plan (Part D) to get coverage for a range of medications.
- Exploring Medicare Savings Programs, such as Extra Help, which assists with drug costs for those with limited incomes.
- Checking if your state offers State Pharmaceutical Assistance Programs (SPAPs) to help with premiums and cost-sharing.
