Drugs and Biologicals

Medicare Part B Drug Coverage

Medicare Part B may provide coverage for medically necessary drugs/biologicals that are furnished “incident to” a physician’s service. This coverage does not apply to drugs that are usually self-administered. 

In a hospital outpatient department, coverage is limited to drugs that are given by infusion or injection. If the injection usually is self-administered or isn’t given as part of a doctor’s service, it is not covered by Medicare Part B. 

The beneficiary is responsible for the annual Medicare Part B deductible and applicable coinsurance for most drugs/biologicals covered under Part B. 

  • Beginning April 2023, the coinsurance amount may be less if a prescription drug’s price has grown faster than the rate of inflation. In most cases, after the person meets the Part B deductible, they’ll pay 0% to 20% of the Medicare-approved amount for covered prescription drugs they get in a doctor’s office. 

Drugs and biologicals are covered when all of the following requirements are met:

  • The medication being given meets the definition of a drug/biologic
  • The drug/biological was administered “incident to” a physician’s service
  • The drug/biological administered is reasonable and necessary for diagnosis or treatment of illness or injury
  • The drug/biological is not on the self-administered exclusion list designated by each MAC
  • It is not an excluded, noncovered immunization
  • It has not been determined by FDA to be less than effective

Posted 3/26/2024