While we wish it was as simple as telling apples from oranges, Medicare Part B and Medicare Part D coverage is quite different in how they cover outpatient drugs. It depends on the drug, where you receive it, and whether you are in Original Medicare or have a Medicare Advantage plan. Understanding how Medicare covers drugs can help you address denials and avoid unnecessary expenses. Below are a few points to help in understanding this difference, summarized by the Medicare Rights Center in one of their Medicare Minute publications.
Point 1: Understand how you get Medicare prescription drug coverage. You can get Medicare prescription drug coverage through a Part D stand-alone prescription drug plan or through a Medicare Advantage Plan that includes prescription drug coverage. The Part B benefit also covers certain prescriptions. You have the Part B benefit regardless of whether you have Original Medicare or a Medicare Advantage Plan.
Point 2: Understand which part of Medicare covers which outpatient prescription drugs. Most outpatient prescription drugs are covered under Part D, as long as they’re on your plan’s formulary, which is the list of drugs they cover. Certain outpatient drugs are covered by Part B, however. For example, Part B should cover your flu shot. Antigens – a type of prescription drug often used to treat allergies – are also covered by Part B, not Part D. The general rule is that Part B covers drugs that usually can’t be self-administered, meaning you need a provider’s help to take or inject them. Part B also covers a limited number of prescriptions from the pharmacy (mainly oral anti-cancer drugs).
Some drugs may be covered by either Part B or by Part D, depending on the situation. For example, if you use an insulin pump, you probably get your insulin and pump from a durable medical equipment supplier, and Part B will cover it. If you inject insulin using a needle, Part D will cover it. If you are a hospital outpatient, Part B should cover all medications that relate to the reason for your hospital visit; however, Part D will cover medications that you administer yourself and do not relate to the hospital visit.
Your pharmacist, your provider, or your plan (when applicable) can help you understand your prescription coverage. For objective counseling and assistance, you can also contact your local Health Insurance Counseling and Advocacy Program (HICAP). HICAP can explain which part of Medicare should cover your drugs, depending upon your circumstances.
Point 3: Understand the costs and coverage for your prescription drugs. Your costs and coverage depend upon which part of Medicare covers your drug. It also depends upon whether you are in Original Medicare or have Medicare Advantage. If you are in a Medicare Advantage Plan, your coverage and costs will depend upon what plan you have. If Part D covers your drug, make sure it is included in your plan’s formulary and that you use a preferred network pharmacy. Under Part D, you typically pay a set co-payment for your medications, after you meet a deductible. However, these amounts will vary depending on your plan and how much you have spent on prescriptions so far this calendar year.
If Part B covers your drug and you are in Original Medicare, you or your supplemental insurance typically pay a 20 percent coinsurance, after meeting the Part B deductible. If you have a Medicare Advantage Plan, your out-of-pocket cost will vary based upon your plan. Those costs may also be higher than the 20 percent coinsurance under Original Medicare. If you get your medications from a pharmacy, make sure the pharmacy will submit claims for your Part B covered drugs to avoid unnecessary expenses.
If Medicare denies coverage for a drug taken as a hospital outpatient, it may be that you can submit the charges to your Part D plan. Contact your plan to find out what steps to follow. You can also contact your SHIP for help understanding your coverage and addressing denials.
If charges for medicines you didn’t receive show up on your Medicare statements, your Medicare number may have been used in a scheme to falsely bill Medicare. If you receive calls offering you a prescription drug discount card and requesting your bank account number, it is a scheme aimed at stealing your money. Contact our California Senior Medicare Patrol program (SMP) for help at 1-855-613-7080.
Action steps to take:
1) Make sure you understand which part of Medicare covers your prescription drugs.
2) If you were denied coverage because your drug was billed to the wrong part of Medicare, contact your plan to find out what steps to follow.
3) If you need help understanding Medicare’s prescription drug coverage or addressing denials, contact your local Health Insurance Counseling and Advocacy Program to discuss your options.
4) If you receive suspicious offers or charges, contact our California Senior Medicare Patrol at 1-855-613-7080 to discuss and report potential abuse or fraud.