Many Medicare beneficiaries seek coverage to supplement their Original Medicare benefits. While Original Medicare – Parts A and B – provides 80% of the payment for any covered services, beneficiaries who wish to reduce their out-of-pocket expenses, even more, enroll in a Medicare supplement, also called a Medigap plan.
What about prescription drug coverage? Are prescription drugs part of Original Medicare coverage? Medigap coverage?
Prescription Drugs and Original Medicare
Medicare Part A offers assistance for inpatient care costs. It will cover your room and board for any inpatient hospital visits. It does not offer assistance for prescription drugs.
Medicare Part B is for outpatient medical services. While it does not cover prescription drugs that you would normally administer yourself at home, it does provide benefits for medications in limited circumstances. Let’s discuss each of these.
Part B covered durable medical equipment (DME). If there are drugs that need to be used with DME, they are covered. This includes nebulizers and infusion pumps.
Antigens that are doctor-prepared and administered by someone who has been instructed on their use (this could be the patient themselves) may be covered by Part B.
Women with osteoporosis may have Part B coverage for injectable osteoporosis drugs. The woman must meet the criteria for the home health benefit and have a bone fracture caused by post-menopausal osteoporosis. A doctor must certify this fact and certify that the woman cannot give herself the injection. While Part B may pay for the prescription, it will not cover the cost of the home health nurse that provides the injection unless other family members or caregivers are unable or unwilling to administer the injection.
Individuals who have End-Stage Renal Disease (ESRD) are eligible for injectable erythropoiesis-stimulating agents. This prescription will also be covered if it is used to treat anemia caused by other conditions. Those with ESDR may also receive oral medications as long as that specific medication is also available by injection, and Part B would cover the injectable form.
Blood clotting factors administered by injection to treat hemophilia are covered under Medicare Part B.
For those who cannot consume food by mouth or cannot absorb nutrition through their intestinal tract, Medicare covers both parenteral and enteral nutrition (tube feeding).
If you’ve been diagnosed with primary immune deficiency disease, Medicare will help pay for the intravenous immune globulin (IVIG) given in your home. As in other cases, a doctor must state that it is medically necessary to do so. Part B does not pay for any items or services required to receive the medication at home – only the medication itself.
Part B covers many vaccinations – pneumococcal shots, flu shots, Hepatitis B shots, and other vaccines if they are directly related to the treatment of an illness.
Organ transplant patients are eligible to receive transplant / immunosuppressive drugs, as long as Medicare helped pay for the organ transplant.
Other injectable and infused drugs may be covered by Medicare when they are administered by a medical provider. If it is not self-administered, it is likely that Part B will cover the prescription.
Prescription Drugs and Medicare Supplements
The rule of Medicare supplements (Medigap plans) is that if the service is covered by Original Medicare, then it is also covered by the Medigap plan. If not covered by Original Medicare, it will also not be covered by the Medigap plan. The rule also applies to prescription drugs.
Medigap plans are created to fill in the “gaps” left by Original Medicare. Premiums and deductibles apply to Original Medicare, and even after those expenses are paid, Original Medicare only covers 80% of the cost of services. This leaves the gap in coverage that Medigap plans were created to pick up.
There are currently ten Medigap plans on the market, all with varying levels of cost and coverage. Like Original Medicare, these don’t cover non-injectable prescriptions that you take at home. Medicare beneficiaries who enroll in a Medigap plan then choose a Part D plan for their prescription drug coverage.
Just like Medigap plans, Part D plans vary by location and drug formulary. Individuals will pick a plan based on their current set of medications. Each year during the Annual Election Period, policyholders may choose to find a new Part D policy, especially if their current plan is changing or their prescriptions have changed.
That being said, there were Medigap plans in the past that did pay for some prescription drugs. If you turned 65 prior to January 1, 2006, you might still have one of these plans.
Medigap Plans with Prescription Drug Coverage
Medigap plans H, I, and J did include limited prescription drug coverage for their policyholders. This coverage was subject to a deductible, and there were caps on how much the plan would pay towards prescription drugs.
Anyone who turned 65 after January 1, 2006, is not eligible for any of these three Medigap plans. Even those who had the plans often dropped the prescription drug coverage they offered when Part D plans became available. Part D plans had fewer limitations and more coverage for prescriptions.
If you currently have a Medigap plan, you will want to enroll in a Part D policy. (You’ll be penalized later if you don’t!) These Part D plans are common and often do not require a very high premium. You will need to find out which plans are available in your area and compare your prescriptions to those offered by the plan.