Most people with prescription drug coverage through Medicare will be using Part D which is a third-party insurance purchased independently from the standard Part A and B Medicare coverage. One exception is for transplant recipients whose transplants were paid for by Medicare. In this instance, anti-rejection drugs will be covered through Medicare Part B, but all other prescriptions will fall under Part D coverage.
In addition to anti-rejection drugs, 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:
Drugs used with an item of durable medical equipment (DME): Medicare covers drugs infused through DME, like an infusion pump or drugs given by a nebulizer, if the drug used with the pump is reasonable and necessary.
Some antigens: Medicare covers antigens if a doctor prepares them and a properly instructed person (who could be you, the patient) gives them under appropriate supervision.
Injectable osteoporosis drugs: Medicare covers injectable osteoporosis drugs if you meet all of these conditions:
- You’re a woman with osteoporosis who meets the criteria for the Medicare home health benefit.
- You have a bone fracture that a doctor certifies was related to post-menopausal osteoporosis.
- Your doctor certifies that you can’t give yourself the injection or learn how to give yourself the drug by injection.
- In addition, Medicare will cover the home health nurse or aide to provide the injection if your family and/or caregivers are unable or unwilling to give you the drug by injection.
Erythropoiesis-stimulating agents: Medicare covers erythropoietin by injection if you have End-Stage Renal Disease (ESRD) End-Stage Renal Disease (ESRD) Permanent kidney failure that requires a regular course of dialysis or a kidney transplant. or you need this drug to treat anemia related to certain other conditions.
Blood clotting factors: Medicare covers clotting factors you give yourself by injection if you have hemophilia.
Injectable and infused drugs: Medicare covers most injectable and infused drugs when a licensed medical provider gives them, because these types of drugs aren’t usually self-administered.
Transplant Specific Coverage
Medicare Part B covers doctors’ services associated with organ transplants, including heart, lung, kidney, pancreas, intestine, and liver organ transplants. It also covers immunosuppressive drugs (transplant drugs) if Medicare paid for the transplant. You must have Part A at the time of the covered transplant, and you must have Part B at the time you get immunosuppressive drugs.
For your transplant and related services, you pay:
- 20% of the Medicare-approved amount for your doctor’s services after you meet the Part B deductible.
- Various costs for transplant facility charges.
- Nothing to the living donor for a kidney transplant.
- Nothing for Medicare-certified laboratory tests.
In 2023, you’ll pay a monthly premium of $97.10* and a $226 deductible if you sign up for the immunosuppressive drug benefit. Once you’ve met the deductible, you’ll pay 20% of the Medicare-approved amount for your immunosuppressive drugs. In 2024, the immunosuppressive drug benefit is expected to increase to $103.00 per month.
*You may pay a higher premium based on your income.
Details on Part B coverage: Organ Transplant Insurance Coverage (medicare.gov)
MM12804 – New Medicare Part B Immunosuppressant Drug Benefit (cms.gov)
As of January 1, 2023, kidney transplant recipients will qualify for lifetime Medicare coverage of their immunosuppressive drugs, regardless of age, if they do not have other insurance coverage. Before this, people who were eligible for Medicare because of end-stage kidney failure (rather than age or disability), lost coverage for their immunosuppressive medications 36 months post-transplant.
For kidney transplant recipients only, the new extended Medicare benefit (Medicare Part B-ID) covers all FDA-approved transplant immunosuppressive drugs indefinitely, no matter your age or disability status. Up to 36 months after transplant, Medicare Part B will cover: FDA-approved transplant immunosuppressive drugs and other transplant medications. For details please visit this link: Medicare Part B-ID Overview for Kidney Transplant Patients | National Kidney Foundation
Please note that this information is subject to change and it’s always best to check with Medicare or a healthcare professional for the most accurate and up-to-date information.
Dawn Levitt, Author 