Unraveling Insurance Coverage: Medication Costs And Your Policy

Medical insurance covers care in a hospital or healthcare provider’s office, and prescription drug insurance pays for the medications you buy at the pharmacy. Health plans will help pay the cost of certain prescription medications, and you may be able to buy other medications, but medications on your plan’s “formulary” (approved list) usually will be less expensive for you. Some insurance companies may provide a one-time refill for your medication after you first enroll.

Prescription drug insurance covers medications bought at the pharmacy

Health plans will help pay the cost of certain prescription medications. You may be able to buy other medications, but medications on your plan’s “formulary” (approved list) usually will be less expensive for you. Some insurance companies may provide a one-time refill for your medication after you first enroll. Ask your insurance company if they offer a one-time refill until you can discuss next steps with your doctor. If you can’t get a one-time refill, you have the right to follow your insurance company’s drug exceptions process, which allows you to get a prescribed drug that’s not normally covered by your health plan. Because the details of every plan’s exceptions process are different, you should contact your insurance company for more information. Generally, to get your drug covered through the exceptions process, your doctor must confirm to your health plan (orally or in writing) that the drug is appropriate for your medical condition based on one or more of the following: All other drugs covered by the plan haven’t been or won’t be as effective as the drug you’re asking for.

Health insurance covers drugs administered in a hospital or office

Health insurance generally covers care in a hospital or healthcare provider's office, and prescription drug insurance pays for the medications you buy at the pharmacy. There are exceptions to this rule. For instance, if you are given a drug in the hospital or office, your medical insurance may pay for it.

Part A (hospital insurance) covers drugs that are part of the treatment you get while you’re an inpatient at the hospital. And Part B (medical insurance) covers things such as injected and infused drugs, such as vaccines, given by a licensed medical provider.

Health plans will help pay the cost of certain prescription medications. You may be able to buy other medications, but medications on your plan’s “formulary” (approved list) usually will be less expensive for you.

Some insurance companies may provide a one-time refill for your medication after you first enroll. Ask your insurance company if they offer a one-time refill until you can discuss next steps with your doctor. If you can’t get a one-time refill, you have the right to follow your insurance company’s drug exceptions process, which allows you to get a prescribed drug that’s not normally covered by your health plan. Because the details of every plan’s exceptions process are different, you should contact your insurance company for more information.

Medicare Part B covers injected and infused drugs

Medicare Part B covers drugs that are infused through durable medical equipment and drugs that are not usually self-administered. Part B covers drugs infused in the home as long as they require administration using a Part B-covered infusion pump and administration of the drug in the home is reasonable and necessary. Part B also covers certain antigens that are prepared by a doctor and given by a properly instructed person under the appropriate supervision. Women with osteoporosis who qualify for home health benefits and certain other criteria can have injectable osteoporosis drugs covered by Medicare Part B. Part B covers calcimimetic medications under the ESRD payment system, including the intravenous medication Parsabiv, and the oral medication Sensipar. Part B also covers drugs provided as part of (or incident to) a physician's service and drugs furnished for use with covered durable medical equipment. Part B covered drugs are infused or injected by physicians such as oncologists, rheumatologists, and urologists.

Medicare Part B pays for covered drugs and biologicals, including covered preventive vaccines, using several methodologies. Average Sales Price (ASP) is the primary methodology used for pricing Part B drugs; however, in the absence of ASP data, CMS may use the wholesale acquisition cost-based prices (WAC). Medicare makes a separate payment to the physician or hospital for administering the drug (that is, for the act of injecting or infusing the product into the patient). The drug administration payment rates are determined under the physician fee schedule or OPPS, depending on the setting of the service.

Medicare Part B covers drugs that are infused through durable medical equipment, including insulin when the use of an insulin pump is determined to be medically necessary. Medicare Part B covers drugs that are infused through durable medical equipment, including insulin when the use of an insulin pump is determined to be medically necessary. Medicare Part B covers drugs that are infused through durable medical equipment, including insulin when the use of an insulin pump is determined to be medically necessary. Medicare Part B covers drugs that are infused through durable medical equipment, including insulin when the use of an insulin pump is determined to be medically necessary. Medicare Part B covers drugs that are infused through durable medical equipment, including insulin when the use of an insulin pump is determined to be medically necessary. Medicare Part B covers drugs that are infused through durable medical equipment, including insulin when the use of an insulin pump is determined to be medically necessary. Medicare Part B covers drugs that are infused through durable medical equipment, including insulin when the use of an insulin pump is determined to be medically necessary.

Employer insurance typically covers common vaccines

If you leave your job, and you no longer have insurance from your employer or COBRA, your prescription drug coverage will almost certainly change. Health plans will help pay the cost of certain prescription medications. You may be able to buy other medications, but medications on your plan’s “formulary” (approved list) usually will be less expensive for you. Some insurance companies may provide a one-time refill for your medication after you first enroll. Ask your insurance company if they offer a one-time refill until you can discuss next steps with your doctor.

Medicare Part D often covers other vaccines

Medicare Part D covers prescription drugs and some common vaccines. Medicare Part D covers CDC-recommended adult vaccines that are not covered under Part B, including herpes. Medicare Part D also covers vaccines directly related to the treatment of an injury or direct exposure to a disease or condition, such as rabies and tetanus.

Medicare Part D covers commercially available inoculations to prevent illness. These include Hepatitis A. The Centers for Disease Control and Prevention (CDC) recommends a hepatitis A shot for children age 12 to 23 months and children age 2 to 18 who weren’t vaccinated earlier. It also recommends the vaccine for adults at increased risk for hepatitis A, including people with chronic liver disease or those who have HIV or work in areas with a risk of infection as well as others at high risk.

Medicare Part D also covers less-common shots. These include immunizations you may need for travel to Africa, Asia, Central and South America, and the Pacific Islands, which are usually covered through Part D without deductibles or copayments if the CDC recommends them for your travel.

Frequently asked questions