- Self-administered drugs are prescription drugs or biologics you take on your own, typically at home.
- You may need self-administered medications for hospital outpatient treatment services (surgery centers, emergency room, outpatient observation).
- Most outpatient self-administered drugs aren’t covered by Medicare Part B.
- Medicare Part D may cover self-administered medications, but you might need to pay up front, then submit a claim for reimbursement.
Self-administered medications are a special category under Medicare coverage. These medications, which you usually take on your own at home, are covered by your Part D (prescription drug) plan.
However, specific coverage rules apply when these medications are provided by a hospital for outpatient services. Medicare Part B covers outpatient hospital stays, but self-administered medications have very limited coverage.
You may have to pay out of pocket for self-administered medications, then submit a claim for reimbursement from Medicare. This could be expensive, so it’s important to understand the coverage rules before your outpatient hospital visit to avoid surprise bills.
Let’s review what self-administered medications are and how they are covered under Medicare.
When you receive outpatient hospital services during an emergency room visit, observation stay, or outpatient surgery center, you may be given medications to take during your stay.
You may be charged for these medications before you leave the outpatient center. You’ll then need to reach out to Medicare for reimbursement.
Hospitals can waive charges or discount the cost of noncovered self-administered drugs given during a covered outpatient stay. However, this depends on the policies of each facility, because the facility can’t bill Medicare for waived or discounted fees.
It’s important to ask questions and be prepared before your outpatient procedure or observation stay whenever possible. You can talk with your doctor and the hospital about charges for self-administered medications ahead of time.
Medicare Part A
Outpatient hospital stays aren’t included in Part A coverage benefits.
Medicare Part B
Medicare Part B is medical insurance for outpatient services like:
- doctor’s visits
- diagnostic tests
- outpatient hospital visits
- some medications
Part B pays 80 percent of the Medicare-approved cost for covered services, but there are exceptions to this coverage.
For example, Part B doesn’t cover a majority of prescription drugs, including self-administered drugs or biologics.
Here are a few points to keep in mind regarding outpatient medication coverage:
- Part B covers only a few medications — typically those given by a nurse or doctor, like injections or intravenous medications.
- Hospital pharmacies generally aren’t part of Medicare preferred provider networks and don’t bill Medicare. This can increase the cost of self-administered outpatient medications compared with what you’d pay for the same drugs with your Part D plan.
- Your cost and reimbursement amount may be affected if you receive the medications out of network (your plan will decide on coverage once you file a claim).
Medicare Part C
Medicare Advantage (Part C) plans cover the same services as original Medicare (parts A and B). Plus, they offer prescription drug coverage and other extras like vision, dental, and wellness programs.
These plans are offered by private insurance plans approved by Medicare. There are many to choose from in every state.
Your Medicare Advantage plan may cover self-administered medications, but you might need to file a claim for reimbursement. Costs can vary based on each plan’s coverage.
If you have a Medicare Advantage plan, check with your plan provider on costs ahead of time, when possible.
Medicare Part D
Medicare Part D plans are also offered through private insurance companies approved by Medicare. These plans cover your prescription medications, including self-administered drugs you take at home.
Keep in mind that medications provided as part of outpatient stays are not automatically covered. You have to file a claim for reimbursement.
Also, if the medications provided by the outpatient facility aren’t on your Part D plan’s formulary (list of covered drugs), you may have to file for an exception or appeal to Medicare for reimbursement.
Part D covers these categories of medications:
- anticonvulsive medications for seizure disorders
- HIV medications
- chemotherapy medications
- antidepressant medications
- intravenous immunoglobulin
- immunosuppressant medications
- antipsychotic medications
Note that this isn’t an all-inclusive list of medications covered by Part D.
Part D plans do not cover:
- over-the-counter medications (such as for cough, allergies, etc.)
- vitamins or supplements
- cosmetic medications, such as for hair loss
- medications for weight loss or weight gain
- medications to treat erectile dysfunction
You can call and check with the hospital and your Part D plan ahead of any scheduled outpatient surgery to find out about coverage policies and costs for self-administered medications.
Medigap supplement plans can help pay for some out-of-pockets costs, such as copayments and deductibles.
If you’re new to Medicare in 2020, you’re not eligible to buy plans that offer coverage for the Part B deductible (Medigap Plans C and Plan F).
Medigap plans also don’t pay for prescription drug costs.
Part B covers certain medications during outpatient hospital stays, but they are not considered “self-administered.” These include:
- Injectables: intramuscular, intravenous medications given by a health professional like biologics, interferon, biologic disease-modifying antirheumatic drugs (DMARDs), antibiotics, etc.
- Certain cancer medications: oral and infused chemotherapy and anti-nausea medications
- Erythropoietin-stimulating drugs: such as epoetin alfa for anemia
- Immunosuppressant medications: such as cyclosporine for use with an organ transplant
Part B may cover some outpatient hospital medications given as part of your complete procedure if they’re part of a “bundled payment” or an essential part of services.
For example, some medications might be covered if they’re part of the outpatient procedure, but this is often up to the hospital and depends on individual situations.
Examples of medications considered a part of complete services include:
- antibiotic ointments for wound or surgical care
- pupil-dilating, anti-inflammatory, antibiotic, or other eye drops provided before, during, or after eye surgery
- sedatives for use during a procedure
- barium or contrast dye for diagnostic imaging
Other medications you’re given for your outpatient stay may be covered by your Part D plan. You still need to pay copayments or coinsurance, and costs may be higher than your usual Part D plan rates.
Medications that are typically not covered during outpatient services include:
- medications provided by a hospital pharmacy to be continued at home after outpatient treatment, such as antibiotics or pain medications
- daily insulin
- laxative or suppository for constipation
- eye drops or ointments used daily
- oral medications for chronic conditions, such as diabetes, high blood pressure, or high cholesterol
Here are some safety tips for taking the following medications at home:
- injectables (intramuscular, subcutaneous — for allergies, insulin, etc.)
- oral (tablets, capsules, liquid)
- nasal spray, inhaler
- topical (creams, ointments, eye drops, ear drops)
- Wash your hands before handling any medications.
- Use a medication reminder app or other tool to keep track of your medications.
- Take your medications at the same time every day, according to a set schedule.
- Use a pill organizer for multiple oral medications.
- Follow directions on how to take the medication, as provided by your doctor and pharmacist.
Self-administered medications are covered under Medicare by separate rules. Both Medicare Part B and Part D coverage may apply and pay for different medications in different situations.
If medications are provided by a hospital pharmacy for your outpatient treatment, you may have to pay up front for any self-administered drugs and seek reimbursement from Medicare.
The hospital may be able to waive or discount charges for self-administered medications. Ask about the hospital’s policy before you receive services.
If you need to file a claim to be reimbursed for medications given to you during your outpatient hospital stay, you can call 800-MEDICARE or visit Medicare.gov to learn more about filing a claim.
It’s a good idea to check your Medicare summary notice to see all your charges.
You can call your Part D plan to ask for an out-of-network pharmacy claim form. File the claim for all self-administered medications provided with an explanation of why you need to be reimbursed.
Your local State Health Insurance Assistance Program (SHIP) can also help with questions about what’s covered.