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.
Medicare Part D Covers Prescriptions at Retail Pharmacy Locations or Mail Order
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.
- Oral cancer drugs: Medicare helps pay for some cancer drugs you take by mouth if the same drug is available in injectable form or is a prodrug of the injectable drug. As new oral anti-cancer drugs become available, Part B may cover them.
- Oral anti-nausea drugs: Medicare helps pay for oral anti-nausea drugs used as part of an anti-cancer chemotherapeutic regimen. The drugs must be administered immediately before, at, or within 48 hours after chemotherapy, and must be used as a full therapeutic replacement for an intravenous anti-nausea drug
Hepatitis B shots: Usually a series of 3 shots covered only for people at high or medium risk for Hepatitis B.
- Injectable osteoporosis drugs: Medicare covers an injectable drug for women with osteoporosis who meet the coverage criteria for the Medicare.
- Immunosuppressive drugs: Medicare covers immunosuppressive drug therapy for people who received an organ or tissue transplant for which Medicare made payment.
Other Prescriptions Covered Under Medicare Part B, not Medicare Part D
- Some other vaccines when they’re directly related to the treatment of an injury or illness (like a tetanus shot after stepping on a nail).
- Durable Medical Equipment (DME) supply drugs: Medicare covers drugs infused through an item of DME, like an infusion pump or a nebulizer.
- Injectable and infused drugs: Medicare covers most injectable and infused drugs given by a licensed medical provider if the drug is considered reasonable and necessary for treatment and usually isn’t self-administered.
- Antigens: Medicare helps pay for antigens if they’re prepared by a doctor and given by a properly instructed person (who could be the patient) under appropriate
- Blood clotting factors: If a person with Medicare has hemophilia, Medicare helps pay for clotting factors they give themselves by injection.
- Parenteral and enteral nutrition (intravenous and tube feeding): Medicare helps pay for certain nutrients for people who can’t absorb nutrition through their intestinal tracts or can’t take food by mouth.
Are You In The Right Medicare Plan?
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.