Navigating Medicare Prescription Drug Coverage

Navigating Medicare Prescription Drug Coverage

Understanding the difference between Medicare Part B and Part D is key to getting the medication coverage you need. This guide breaks down everything you need to know.

What Does Medicare Cover?

Medicare Part B covers a limited set of outpatient prescription drugs administered by a doctor or health care professional. This includes injections, infusions, and oral cancer drugs.

Medicare Part D covers most other outpatient prescription drugs you pick up at the pharmacy. This includes drugs that treat common conditions like high cholesterol, high blood pressure, diabetes, asthma/COPD, and depression.

Part B Prescription Drug Coverage

Part B covers injectable or intravenous drugs under specific circumstances. Here are some examples:

• Chemotherapy drugs: Oral chemotherapy and anti-nausea drugs given as part of a chemotherapy regimen.
• Immunosuppressants: Drugs for people who have had an organ transplant covered by Medicare.
• Osteoporosis drugs: Injectable osteoporosis drugs for women with osteoporosis-related fractures.
• Blood clotting factors: Clotting factors given to people with hemophilia.

Part B also covers all commercially available vaccines needed to prevent illness. This includes:

• COVID-19 vaccine
• Flu shot
• Pneumonia shot
• Hepatitis B vaccine (for at-risk groups)
• Tetanus shot (with dirty wounds)
• Rabies vaccine (after animal bites)

Preventive vaccines under Part B have $0 cost-sharing as long as your provider accepts Medicare assignment. You pay 20% coinsurance for other shots like rabies and tetanus.

Part D Prescription Drug Coverage

Part D plans cover most other prescription drugs that treat common medical conditions. Each plan must cover at least two medications per therapeutic category.

Your out-of-pocket costs under Part D depend on factors like:

• The tier your drug falls under
• Whether your drug is on your plan's formulary
• What phase of coverage you're in
• Extra coverage in MA-PD plans

Part D plans cannot charge you more than 25% coinsurance on covered brand and generic drugs. But if you need specific or more extensive coverage, your premiums may exceed the basic standard premium ($31.50 per month in 2023).

How Parts B and D Work Together

Part B covers provider-administered drugs. Part D covers prescriptions you fill yourself. It's important to know which drugs fall under each part to minimize your out-of-pocket costs.

In the hospital, your drug coverage depends on your admission status:

• Inpatient stay: Drugs covered under Part A
• Observation stay: Part B covers IV drugs, Part D may cover other drugs

Understanding whether you'll be admitted as inpatient or placed on observation is key to avoiding surprise bills for medications.

Strategies to Reduce Prescription Costs

Medicare Part D plans and Medicare Advantage plans now have more power to negotiate drug costs under the Inflation Reduction Act. This should help limit how much you pay out-of-pocket for medications.

Other steps to cut prescription costs include using lower-tier medications when possible, comparing Medicare plans during open enrollment, and exploring financial assistance programs.

Understanding Medicare prescription drug coverage puts you in control of your healthcare costs. Now you can navigate Part B vs. Part D and choose the plan that saves you the most money.