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Medicare Part D: How The Finances Work

Drugs Which Are Covered Under Original Medicare Part B

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Prescription Drugs (Outpatient) Limited Coverage

Part B covers a limited number of outpatient prescription drugs, and only under limited conditions. Generally these include drugs you would not usually give to yourself, that you get at a doctor’s offi ce or hospital outpatient setting. Doctors and pharmacies must accept assignment for Part B drugs, so you should never be asked to pay more than the coinsurance or copayment for the drug itself.
The following are examples of drugs covered by Part B:
  • Oral Cancer Drugs: Medicare will help pay for some cancer drugs you take by mouth if the same drug is available in injectable form. Currently, Medicare covers the following cancer drugs you take by mouth:
    • Capecitabine (Xeloda®) 
    • Melphalan (Alkeran®)
    • Busulfan (Myleran®) 
    • Temozolomide (Temodar®)
    • Cyclophosphamide (Cytoxan®) 
    • Topotecan (Hycamtin®)
    • Etoposide (VePesid®) 
    • Methotrexate (Rheumatrex®
    • Trexall®)
        Medicare may cover new cancer drugs as they become available.
  • Oral Anti-Nausea Drugs: Medicare will help 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 and must be used as a full therapeutic replacement for the intravenous anti-nausea drugs that would otherwise be given.
  • Infused Drugs: Medicare covers drugs infused through an item of durable medical equipment, such as an infusion pump or nebulizer if considered reasonable and necessary.
  • Some Antigens: Medicare will help pay for antigens if they’re prepared by a provider and given by a properly-instructed person (who could be the patient) under appropriate supervision.
  • Injectable Osteoporosis Drugs: Medicare helps pay for an injectable drug for osteoporosis for certain women with Medicare. 
  • Erythropoisis–stimulating Agents: Medicare will help pay for erythropoietin by injection if you have End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant) or need this drug to treat anemia related to certain other conditions.
  • Blood Clotting Factors: If you have hemophilia, Medicare will help pay for clotting factors you give yourself by injection.
  • Injectable Drugs: Medicare covers most injectable drugs given by a licensed medical provider, if the drug is considered reasonable and necessary for treatment. 
  • Immunosuppressive Drugs: Medicare covers immunosuppressive drug therapy for transplant patients if the transplant meets Medicare coverage requirements, the patient is enrolled in Part A at the time of the transplant, and the patient is enrolled in Medicare Part B at the time the drugs are dispensed. 
Note: Medicare drug plans may cover immunosuppressive drugs, even if Medicare or an employer or union group health plan didn’t pay for the transplant.

In 2010, YOU pay 20% of the Medicare-approved amount for covered Part B prescription drugs that you get in a doctor’s offi ce or pharmacy. In a hospital outpatient setting, you pay a copayment. However, if you get drugs in a hospital outpatient setting that aren’t covered under Part B, you pay 100% for the drugs unless you have Part D or other prescription drug coverage. In that case, what you pay depends on whether your drug plan covers the drug, and whether the hospital is in your drug plan’s network. Contact your prescription drug plan to find out what you pay for drugs you get in a hospital outpatient setting.

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