If you’re in the wrong type of Medicare coverage, you may be paying a whole lot of money for prescription drugs billed under Medicare Part B, not Medicare Part D. This is especially true if you get cancer. How can this be? Read on.
Medicare Part D covers Prescription Drugs, right? Not always… Medicare Part B can play a big role. In fact, there are many instances when Medicare Part D actually doesn’t cover all drugs you may need during the course of your healthcare. When medical conditions get serious, many medications aren’t covered by Part D. Instead, they’re covered by Part B. Knowing the difference between the two could save you hundreds if not thousands of dollars when choosing your Medicare coverage. This is especially true if you have cancer as chemotherapy drugs and all the associated medications that come into play during cancer treatment are extremely expensive.
Generally, Part D covers prescription drugs at a retail or mail-order pharmacy. Let’s say you get bronchitis; you make an appointment with your primary care physician, he/she sends your prescription into your local pharmacy. When you pick it up, you pull out your PDP or your MAPD card, swipe it and pay the associated copay or coinsurance. Simple, right? Right.
But what if you need a prescription drug that’s administered by a doctor? Let’s say you have macular degeneration, and you’re seeing an ophthalmologist for treatment. Many folks with this condition get very expensive shots in the eye to slow the degeneration. Clearly (no pun intended) you can’t do this yourself. When this happens, the doctor actually bills the prescription under Medicare Part B, not Medicare Part D.
Same goes for prescription drugs that are administered in an outpatient setting. If you’re having your knee scoped or drained, and the doctor shoots localized anesthesia into your knee before the procedure, that will hit Medicare Part B, not D.
So, generally, Part B covers drugs that usually aren’t self-administered, which is a fancy way of you’re not taking them by yourself. The doctor, nurse practitioner, surgeon, anesthesiologist, etc. are giving them TO you.
Here’s a short list of medical conditions that, when prescription drugs are used in your treatment, are covered under Medicare Part B, and not covered under Medicare Part D.
Hepatitis B shots: Usually a series of 3 shots covered only for people at high or medium risk for Hepatitis B.
Here’s where it gets interesting. If you have a Medicare Supplement Plan (Medigap), these drugs are usually covered at 100%, especially for the two most popular plans, Medigap C and Medigap F. That’s because these plans cover 100% of the Medicare Part B costs, which includes the deductible and any associated coinsurance. The third most popular Medigap plan is Plan N, and if you have this one you’d be covered at 100% after paying the Part B deductible.
If you’re on a Medicare Advantage (MAPD) plan, odds are you’ll be paying 20% of the cost for Part B drugs, all the way up to the annual Maximum Out Of Pocket (MOOP). To make sure, you need to pull out your Annual Notice of Change or your Summary of Benefits right now. Flip to the Section entitled, “Medicare Part B drugs.” If I were a betting man, (and I’m not) I’d bet you right now your MAPD plan doesn’t cover Medicare Part B drugs any more than at an 80% level, leaving you 20% to pay. You stand a very good chance of hitting your MOOP very quickly if you have cancer, or any other serious condition requiring hospitalization involving prescriptions administered by hospital staff.
If you’re turning 65 or otherwise now eligible for Medicare, this is an often overlooked “gap” in traditional Medicare, as well as most Medicare Advantage plans. Most agents breeze right by this section in their presentations, and it’s not prominently one of the topics in “educational” presentations or seminars. But, you clearly need to pay attention to it since over 1.6 Million people in the United States will get cancer in a given year. Chemotherapy drugs are not cheap by any stretch of the imagination if you happen to be stricken with cancer and neither are osteoporosis drugs.
If you’re playing it safe and this gap is of concern to you, I’d seriously consider getting a Medicare Supplement plan, if you can afford the monthly premium. 9 out of 10 times, a MAPD plan is going to be cheaper (along with a whole other set of considerations, click here for more on those) but you’ll have to cough up 20% of the Part B drugs if you need to.
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Author Bio: Ben started Prepare for Medicare in 2014 to help people help people get objective answers to questions about Medicare. He’s held leadership roles at numerous Fortune 500 Medicare health insurers in product development, sales, marketing and strategy for over 20 years.