By Tolu Ajiboye
Medicare can be quite confusing, particularly when it comes to prescription drug coverage. Knowing what each part covers (and doesn't) will enable you to navigate the system better and help you better choose the plan that will be most beneficial to you.
Here’s what you need to know about Medicare Part B and Medicare Part D, what they cover and what your costs are under them.
Medicare Part B
Medicare part B (Medical Insurance) is mainly for outpatient benefits - such as doctor visits - and it is a part of Original Medicare.
It covers services and supplies that are considered medically necessary to diagnose and treat your condition. This includes doctors’ services, outpatient care, home health services, durable medical equipment, ambulance services and mental health services. It also covers preventive services like pap smears, screening mammograms, and flu shots.
Medicare Part B typically covers outpatient services, but it may also cover partial hospitalization for mental healthcare if your doctor certifies that the only other option is to admit you as an inpatient.(1)
Clinical research studies and the acquisition of a second opinion before a medically necessary surgery is also covered under Medicare Part B.
Although it’s not a prescription drug plan, Part B does covers certain drugs that cannot be self-administered too. (2)
Your Costs Under Medicare Part B
There are certain payments you need to make under Medicare Part B. They include:
When you’re enrolled in Medicare Part B, you have to pay a monthly premium. The amount you are required to pay depends on your income, but the minimum amount an individual would pay in 2019 is $135.50 per month, while the maximum is $465.50 per month. These figures change yearly.
You must pay a deductible to gain access your Medicare Part B benefits. For the year 2019, this deductible is $185. Until you pay this amount in full, you will pay the entire Medicare-approved costs for services you receive under Part B.
After your deductible is paid, you will start to pay 20% of the Medicare-approved amount for most of the services you receive under Part B. Medicare will pay the remaining 80% as long as your healthcare provider accepts Medicare assignment. ‘Assignment’ means the provider accepts to be paid directly by Medicare at the payment rate approved by Medicare for the particular service.
However, you don’t have to pay anything for most preventative services once the healthcare provider handling the service accepts assignment.(3) Also note that there is no cap on the 20% coinsurance for which you are responsible.
Medicare Part D
Medicare part D is the optional prescription drug benefit for anyone with Medicare coverage. You must have Medicare Part A and/or B coverage to be able to get Medicare Part D.
Medicare Part D basically adds prescription drug coverage to the Original Medicare (Part A and B), some Medicare Private Fee-for-Service (PFFS) Plans, some Medicare Cost Plans and Medicare Medical Savings Account (MSA) Plans. Most Medicare Advantage plans already include Medicare Part D.
According to the Centers For Medicare and Medicaid (CMS), Part D medications have to be:
- Available only by prescription (over the counter medications are not covered)
- Not available under part A or B coverage
- Approved by the Food and Drug Administration
- Used and sold in the U.S.
- Included on the formulary of the plan.
There are many different Part D plans you can choose from. In addition to referring to these plans as Part D plans, you will also see them referred to as Prescription Drug Plans or PDPs. Each PDP has its own formulary (a list of prescription drugs covered by the plan). Some drugs, however, like all vaccines that are commercially available, are mandatorily included in the formularies of all Part D plans.(4) Medicare provides prescription drug look-up tools so that you can ensure the medications you take are on the formulary of the Part D plan you select.
Your Costs Under Medicare Part D
The monthly premium you are required to pay varies from plan to plan. If your Medicare Advantage plan includes drug coverage, you will not have to pay a separate premium for it.
With some plans, you have to pay a yearly deductible before you can start to receive coverage for the drugs, while with others, you don’t.
After you've paid your deductible (if required), you will then start paying your share for the covered drugs. The price of each drug, and thus the percentage you’ll pay as coinsurance varies with each individual plan.
Medicare Part D is only available through Medicare-approved private insurance companies. This means that you have to sign up for the plan of your choice with the private insurer directly. (5) Individuals may also be eligible for "Extra Help" for their Medicare Part D plan. This is available to help those with lower incomes to afford the premium and prescription drug costs in a Part D plan.
Items covered by Part B and not Part D
Although Medicare Part D is your prescription drug coverage, you may need to use Part B to gain access to certain drugs, as any drug that is covered by Part B is automatically excluded from coverage by Part D.
Medicare Part B typically covers drugs that aren’t self-administered as well as those given as part of a doctor’s service. These drugs include:
1. Certain vaccines:
- Flu Shots
- Pneumococcal shots: You can take the first shot at any time, but Part B will only cover the second shot if you take it at least one year after the first one.
- Hepatitis B shots: This is only covered if you are at medium or high risk for hepatitis B.
- Some other vaccines are covered if they’re directly related to/necessary for the treatment of a condition or injury. For example, getting a tetanus shot while you’re being treated for a puncture wound.
Since these vaccines are preventative, you don’t pay anything if your doctor accepts assignment.
2. Injectable and infused drugs that are given by a licensed provider and are considered necessary for your treatment.
3. Drugs used with durable medical equipment (such as nebulizers and suction pumps) that are already covered by Part B.
4. Injectable osteoporosis drugs for women who have a bone fracture and already qualify for the Medicare home health benefit, and whose doctor certifies that the fracture was related to post-menopausal osteoporosis. The doctor must also certify that the woman cannot learn to self-administer the drug by injection.
5. Antigens prepared by a doctor and administered by a properly instructed person (which could be you) under supervision.
6. Blood clotting factors if you have hemophilia and self-administer the drugs by injection.
7. Erythropoiesis-stimulating agents, given by injection, if you have end-stage renal disease (ESRD) and require them to treat anemia. If you need to treat anemia with these drugs, but don’t have ESRD, you may also receive coverage for them.
8. Immunosuppressive drugs if you had an organ transplant that was covered by Medicare.
9. Oral anti-nausea drugs if they form part of your chemotherapeutic cancer treatment plan.
10. Oral cancer drugs that are also available in injectable form.
11. Intravenous and tube feeding if you're unable to eat food directly or absorb nutrients through your gastrointestinal tract.
12. Intravenous Immune Globulin (IVIG) if you have primary immune deficiency disease. The drugs must be given to you in your home. Medicare does not cover any costs incurred in the process of getting the drug to your house. (6)
(1)Mental health care (partial hospitalization). Medicare.gov. https://www.medicare.gov/coverage/mental-health-care-partial-hospitalization
(2)(5)THE OFFICIAL U.S. GOVERNMENT MEDICARE HANDBOOK. Medicare & You. 2019. https://www.medicare.gov/sites/default/files/2019-05/10050-Medicare-and-You.pdf
(3)Part B costs. Medicare.gov. https://www.medicare.gov/your-medicare-costs/part-b-costs
(4)(6)Tipsheet. Medicare Drug Coverage under Medicare Part A, Part B, Part C, & Part D. Centers For Medicare and Medicaid Services. https://www.cms.gov/outreach-and-education/outreach/partnerships/downloads/11315-p.pdf