Medicare Coverage for Hospital Outpatient Drugs
What Does Medicare Part B Cover?
Medicare Part B generally covers care in hospital outpatient settings like:
- Emergency departments
- Observation units
- Ambulatory surgery centers
- Pain clinics
It also covers certain drugs administered in these settings—such as medications given through an IV.
What About Self-Administered Drugs?
Self-administered drugs are medications you would normally take on your own (e.g., daily pills for blood pressure or diabetes). Part B usually doesn’t cover these when you’re treated in an outpatient hospital setting.
If you receive self-administered drugs in this setting and they aren’t covered by Part B, the hospital may bill you directly.
How Medicare Part D Comes Into Play
If you’re enrolled in a Medicare drug plan (Part D), it may cover these drugs. However, Part D plans:
- Only cover prescription drugs on their formulary (drug list)
- Do not cover over-the-counter (OTC) drugs like aspirin or laxatives
- May require you to pay upfront if the hospital pharmacy doesn’t participate in Part D
After paying, you can submit a claim to your Part D plan for reimbursement.
Tips to Avoid Surprise Costs
- Check with the hospital ahead of time to see if they participate in Part D.
- Bring your current medications or a complete drug list when you go to the hospital.
- You can’t regularly get your self-administered prescriptions through the hospital outpatient or ER as a routine method.
Out-of-Pocket Costs and Reimbursement
If your Part D plan covers the drug:
- You may still owe any deductibles, copays, or coinsurance
- You might have to pay the difference between the hospital’s charge and what your plan reimburses
- These costs will count toward your Part D out-of-pocket maximum
If your plan doesn’t cover the drug, you’ll need to pay the full hospital charge.
What If Your Drug Isn’t Covered?
You can:
- Request an exception to have the drug covered
- Appeal your plan’s decision
Check your plan’s enrollment materials or contact your Medicare drug plan at directly for help with appeals.