Self-administered drugs are medications that you take yourself. If you need them while hospitalized or during outpatient treatment, Medicare Part B may not apply, and you may need reimbursement from Part D.
Read on to learn more about self-administered drugs, how they’re determined, and how you can get coverage.
Generally, Medicare covers medications in two ways. Part B of Original Medicare pays for any drugs medical professionals need to administer while you’re hospitalized or undergoing outpatient treatment, such as intravenous (IV) medications, whereas Part D pays for regular prescription drugs you get from a pharmacy.
In many cases, you might not be allowed to bring your medications from home, and hospital pharmacies often don’t contract with Medicare Part D. Therefore, your medical facility will have to provide you with a maintenance supply of these drugs at a separate cost.
First, Medicare coverage only applies to prescribed medications. This means that you’ll be billed out of pocket for any over-the-counter drugs you need to take.
In addition, Part B generally doesn’t cover self-administered drugs. If your medication is normally covered by Part D, you can get reimbursement after paying out of pocket.
However, you may need to prove that you could not reasonably have gotten the drug through a Medicare-approved pharmacy during or before the procedure.
If you have Medicare Advantage (Part C), your plan will offer the same coverage as Original Medicare, which will not pay for self-administered drugs. However, some Advantage plans include prescription drugs and may provide coverage.
The Part D formulary lists all the prescription medications covered under Part D. In addition, the Centers for Medicare & Medicaid Services (CMS) lists drugs generally considered self-administered.
CMS also lists criteria that define when a drug might or might not be deemed self-administered. For example, drugs administered through an IV, through the muscle, or into the skin will never be considered self-administered.
On the other hand, oral medications, suppositories, topical medications, and inhaled drugs will generally be viewed as self-administered.
That said, there can be exceptions to this list, and Medicare deems drugs as usually self-administered if you take them yourself more than 50% of the time.
The cost of drugs varies widely. If your medication is an over-the-counter drug, you’ll have to pay the full cost, which depends on the drug.
With prescribed self-administered drugs, you may have to pay the full cost out of pocket initially. However, if the drug is in the Part D formulary, then Part D should reimburse the cost.
According to the Congressional Budget Office, the average prescription drug price after subtracting manufacturer and governmental discounts was around $50 for generic drugs in 2018 and as high as $353 for brand-name drugs.
What you pay depends on your Part D premium, copayments, and deductible if you haven’t fully met it. The average monthly premium for Part D is around $55.50, but all these costs can vary by plan.
Does private insurance cover self-administered drugs?
Some private insurance plans may cover self-administered drugs, depending on your specific plan.
What are examples of self-administered drugs?
Generally, any drug you can take yourself is self-administered. When you swallow a pill yourself as opposed to getting IV treatment of a medication in a clinic is one example. Another specific example of a self-administered drug is insulin because you’re injecting it yourself.
How do I bill Medicare for self-administered drugs?
If your self-administered drug is covered under part D, you can file a claim for reimbursement.
You begin by filling out a reimbursement form, which is also available in Spanish. Then you submit the completed form, along with the bill you got from your insurance provider and a letter explaining the reason for the claim.
You can also include any supporting documents that might help. You can find the submission address with more detailed instructions on the Medicare website.
Self-administered drugs are medications that you take on your own.
Generally, Part B of Original Medicare covers any drugs that medical professionals administer while you are hospitalized or receiving outpatient treatment, including IV medications. On the other hand, Part D is responsible for covering regular prescription medications you get from a pharmacy.
However, during a hospital stay or outpatient treatment, Part B may not apply, and you may need to get reimbursement from Part D.