Prescription drugs (outpatient)

Medicare Part B (Medical Insurance) covers a limited number of outpatient prescription drugs under certain conditions.

Usually, Part B covers drugs you wouldn't typically give to yourself, like those you get at a doctor's office or in a hospital outpatient setting .

Here are some examples of Part B-covered drugs:

• New Alzheimer’s drug (Leqembi, generic name lecanemab): Medicare covers a new type of medication to slow or delay symptoms of Alzheimer’s. Talk to your provider about whether this drug is right for you.
  • This drug doesn’t cure or reverse Alzheimer’s disease.
  • The drug is given intravenously (through a vein) in a provider’s office or other outpatient setting.
  • If you and your provider decide this treatment is right for you, your provider will submit data as part of an effort to understand how well this new medication works as part of your care. This is part of the process so Medicare will cover the drug.

  Part B covers calcimimetic medications under the ESRD payment system, including the intravenous medication Parsabiv, and the oral medication Sensipar.

  Your ESRD facility is responsible for giving you these medications either at the facility or through a pharmacy they work with. You’ll need to talk to your ESRD facility staff and your health care provider to find out:

  • Where you’ll get these medications
  • How much you’ll pay
  • Parenteral and enteral nutrition (intravenous and tube feeding): Medicare covers certain nutrients if you can’t absorb nutrition through your intestinal tract or take food by mouth.
  • Intravenous Immune Globulin (IVIG): Medicare covers IVIG you get at home if both of these conditions apply:
    • You've been diagnosed with primary immune deficiency disease.
    • Your health care provider decides that it's medically appropriate for you.

    Part B also pays for other items and services related to you getting the IVIG at home.

    If you only have Medicare because of End-Stage Renal Disease (ESRD), your Medicare coverage (including immunosuppressive drug coverage) ends 36 months after a successful kidney transplant. Medicare offers a benefit that helps you pay for your immunosuppressive drugs beyond 36 months if you don’t have certain types of other health coverage (like a group health plan, TRICARE, or Medicaid that covers immunosuppressive drugs). This benefit only covers your immunosuppressive drugs and no other items or services. It isn’t a substitute for full health coverage. If you qualify, you can sign up for this benefit any time after your Part A coverage ends. To sign up, call Social Security at 1-877-465-0355. TTY users can call 1-800-325-0788.

    Your costs in Original Medicare

    • Doctors, other health care providers, and pharmacies must accept assignment for Part B-covered drugs, so they should never ask you to pay more than the coinsurance or copayment for the Part B-covered drug itself.
    • In most cases, after you meet the Part B deductible , you pay up to 20% of the Medicare-approved amount for covered Part B prescription drugs.
      • Your coinsurance amount can sometimes change depending on your prescription drug's price.
      • You might pay a lower coinsurance for certain Part B covered drugs and biologicals you get in a doctor's office, pharmacy, or outpatient setting, if their prices have gone up faster than the rate of inflation. The specific drugs and potential savings change every quarter.

      Things to know

      Medicare drug plans (Part D) cover many drugs that Part B doesn't cover. If you have Original Medicare, you can join a Medicare drug plan to get Medicare drug coverage. If you join a drug plan, check your plan's drug list (also called a formulary ) to find out what outpatient drugs it covers.

      Part D generally covers all other recommended adult immunizations (like shingles, tetanus, diphtheria, and pertussis vaccines) to prevent illness. Talk to your provider about which ones are right for you. You can now get more vaccines under Part D at no cost to you. Contact your plan for details.

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