Unraveling Medicare Drug Coverage

Coverage for medications within the Medicare system can, not surprisingly, be a confusing and complex topic.  Many people believe that all drugs are covered under their Part D prescription drug plan. However, Medicare is comprised of four "Parts" and medications may be covered under each depending on the situation.

PART A - Inpatient / Hospital Coverage
While Part A covers you when admitted to the hospital or a skilled nursing facility (SNF), you may also have covered drugs during your stay.  Generally, any payments made to the hospital or SNF will include coverage for all medications administered during your period of inpatient care.

PART B - Outpatient / Medical Coverage
​Typically, coverage for medications under Part B are limited to those that are not self-administered. These would be medications that are delivered via injection or infusion within a hospital outpatient setting or other medical facility.  Note that injections usually administered by the patient do not fall in this category and would generally fall under your Part D coverage.  Medications covered under
Part B will be subject to the annual deductible, which is $166 in 2016. Those expenses do not apply toward the Part D deductible or "Donut Hole" limits.

Medication coverage under Part B may include:

• Vaccinations for flu, pneumococcal, and hepatitis B
• Medications delivered via durable medical equipment, such as an infuser
• Injectable drugs given by a licensed medical provider deemed reasonable and necessary
• Oral anti-nausea medication associated with chemotherapy
• Certain nutritional supplements delivered via feeding tube

Part C - Medicare Advantage
Medicare Advantage (MA) is a private insurance alternative to Original Medicare. These plans must offer the same medication coverage as Parts A & B.  Additionally, most people participating in MA also receive Part D prescription drug benefits.  It is important to note that an individual may not be enrolled in Medicare Advantage and purchase a separate Part D plan.

Part D - Prescription Drug Plan
These plans are the traditional option selected by participants in Original Medicare, which means they are purchasing individual components for Medicare benefits.  That vast majority of prescription drugs will be covered under this plan if not applied to Part A or B as outlined above. Most Americans will have several plans available and they are not all the same.  It is very important to regularly review your drug coverage plan, particularly during open enrollment each year.  (October 15-December 7)  

Insurance companies will change their formularies (i.e. how they cover a medication), pharmacy networks and supplemental benefits annually.  Ignoring these changes or those related to your healthcare needs will frequently result in unnecessary out of pocket expense increases.

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Have questions about this article or your specific medication coverage?  
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