Self-administered drugs are medications a person can take at home, without assistance. Generally, Medicare does not pay for self-administered drugs when doctors prescribe them in an outpatient hospital setting.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Generally, a person takes self-administered medications at home, and Medicare Part D plans may cover the drug costs.
However, there may be occasions when a person in an outpatient hospital setting may need their regular, self-administered medications. This category may include drugs to control blood pressure, diabetes, or other health conditions.
Most hospital settings will not allow people to bring their medication from home. Therefore, a person may have to pay out-of-pocket costs for their self-administered drugs while in an outpatient setting and then claim for reimbursement.
Medicare is a federally funded health plan for people aged 65 and older and some younger people with certain conditions or disabilities.
The program consists of:
- original Medicare (Part A and Part B) for hospital and medical insurance
- Part C, also called Medicare Advantage, as an alternative to original Medicare
- Part D for prescription drug coverage
Different parts of Medicare offer various coverage options.
Medicare Part A covers inpatient hospital stays, as well as some hospice and home health services. However, it does not include doctor fees during a hospital stay, nor does it cover drugs provided in an outpatient setting.
Learn more about Medicare Part A here.
Medicare Part B generally pays for healthcare — including drugs administered intravenously or through an injection — in an outpatient setting, such as an emergency room, surgical center, or pain clinic.
The medications covered by Part B during a person’s stay in an outpatient setting may include injectables, immunosuppressants, erythropoietin-stimulating drugs, and some cancer medications.
In addition, if a medication is considered part of the service, it is possible that Part B will cover it. Such medication would typically include sedatives and anti-inflammatory or antibiotic ointment.
Learn more about Medicare Part B here.
Medicare Part C, also known as Advantage, may include prescription drug coverage. Medicare-approved private companies offer these plans, and coverage and costs vary.
A person can check with their plan provider whether they cover self-administered drugs. If they are not on the provider’s list of drugs, a person may have to claim for reimbursement.
Learn more about Medicare Part C here.
Private insurance companies offer Medicare Part D plans, which generally cover both brand-name and generic drugs. However, the plans do not pay for over-the-counter drugs, such as cold medicines or laxatives.
Medicare does not pay for self-administered drugs in an outpatient setting, and a person may need to cover the medication costs upfront. Some healthcare facilities may lower or waive the charges, depending on their policies.
A person can ask Medicare for reimbursement, and Medicare Part D may help cover these costs. A person will need information about their outpatient visit, including a bill showing the prescribed drugs.
There are several costs a person has to pay.
Part B coverage generally extends only to intravenous medications or those that a doctor or nurse administers by injection.
In general, after a person has met their annual 2021 deductible of $203, Medicare Part B pays 80% of the Medicare-approved cost for covered services, although it covers only a few prescription drugs. Uncovered drugs include the self-administered ones.
Also, as most hospital pharmacies do not belong to the Medicare referred provider network, they do not bill Medicare. Therefore, a person may pay more for self-administered drugs provided in an outpatient setting. However, the final cost will depend on the medication and healthcare facility.
In addition, a person must pay their Part B monthly premium, which amounts to $148.50 in 2021 for a person who has an income of $88,000 per year or less.
A person can check with their plan provider for covered self-administered drugs, as they may have to file a claim for reimbursement.
Costs vary among Advantage plans, and a person must also pay their original Medicare premiums. In 2021, the Medicare Part B premium is $148.50. Most people do not incur a cost for Medicare Part A.
Some companies offer Advantage plans with zero premiums, although the average monthly premium in 2021 is an estimated $21.00, according to the Centers for Medicare and Medicaid Services. A person will also have costs for their plan’s annual deductibles, copays, and coinsurance.
Before a scheduled outpatient procedure, a person can check with their Part D provider about covered costs for their self-administered medications.
In addition, a person will need to check whether the drugs given by the outpatient facility are on their Part D provider’s list of covered drugs. If the medications are not on that list, a person may have to appeal to Medicare for reimbursement or file an exception.
Learn more about Medicare reimbursement here.
A person will also have to pay their Medicare Part D premium, which varies depending on the plan and location. According to the Kaiser Family Foundation, the average monthly premium for Medicare Part D in 2021 is $33.06. There may also be coinsurance or copays.
There are several local and national programs that may help a person with costs:
- Council on Aging: Older adults with health concerns may get assistance, including prescription drug coverage as an outpatient.
- Extra Help: This program for people with limited income aims to reduce the cost of drugs, setting the costs at no more than $3.70 for generic drugs and $9.20 for brand-name drugs.
- Medicaid: This joint federal and state program is for people with limited income and resources, and it may help with healthcare costs.
- Medicare savings programs: These programs may provide assistance with the payment of premiums, deductibles, and prescription drug costs.
- Pharmaceutical Assistance Programs: Drug companies run these programs, which may help pay for prescription costs. The online tool can help a person check whether their plan covers their self-administered drugs.
- State Pharmaceutical Assistance Program: Many states have a support program. People can use the online tool to check whether their state offers such a program.
- StateRxPlans.us: This resource offers information about prescription assistance plans available in states across the country, which may give free drug cards to help a person lower drug costs. The listed programs show the lowest price for prescription drugs at various pharmacies across the country.
Self-administered drugs are prescriptions a person normally takes at home, such as drugs to manage high blood pressure or diabetes. Medicare Part B does not pay for these drugs in a hospital outpatient setting, and hospital pharmacies do not usually participate in Medicare Part D.
People may have to pay for the medication out of pocket and then apply for reimbursement. Some programs may help with costs, such as premiums and deductibles, and certain medications.