Does Original Medicare Cover Prescriptions?

A common concern among Medicare beneficiaries is the cost of prescription medications. There’s good reason for this concern, too, since Medicare didn’t offer prescription coverage for the first 40 years of the program.

Things are different today, although prescription costs remain an expensive part of our healthcare expenses. Still, you won’t find much prescription coverage under Original Medicare (Parts A and B). It does offer coverage for some prescriptions, namely those administered in a clinical setting or during an inpatient hospital stay, like injectible or infusion medications given by a doctor. Other outpatient prescriptions are still not covered by Medicare.

Medicare Part D came around in 2006, offering beneficiaries a way to get prescription drug coverage. You’ll have the opportunity to enroll in a Part D plan when you become eligible for Medicare.

Today, we’ll take a closer look at each part of Medicare to learn more about which prescriptions are covered.

Medicare Part A Prescription Coverage

Medicare Part A offers inpatient coverage at hospitals and skilled nursing facilities. During an inpatient stay, Part A will usually cover any medications given to you as part of your treatment. For example, it will pay for anesthesia administered during a surgery.

The main requirement for getting a prescription covered under Part A is to have that medication given during your inpatient stay. Part A won’t cover prescriptions at any other time.

While Part A will offer coverage during your hospital stay, you’ll still be responsible for the Part A deductible and any copayments. In 2024, that deductible is $1,632 per benefit period, which generally equates to one hospital stay. You won’t have any copays until you’ve been hospitalized for 60 days.

Medicare Part B Prescription Coverage

Medicare Part B offers outpatient coverage for things like doctor’s visits, durable medical equipment (DME), lab tests, diagnostic images, preventive care, and more. If, during any of those doctor’s visits, you have medication administered to you, you might have coverage for that medication under Part B.

Most Part B covered drugs are injectable, intravenous, or infusions - medications you can’t necessarily administer yourself. Drugs that fall into this category can include:

• Vaccines

• Drugs administered through DME (like a nebulizer or insulin pump)

• Immunosuppressive drugs

• Oral cancer drugs

• Anti-nausea drugs

• Antigens

• Nutrition (tube-feeding)

You may also have Part B prescription coverage if you have rheumatoid arthritis, psoriasis, or inflammatory bowel disease.

Like Part A, Part B does have cost-sharing responsibilities. The first step is to meet your Part B deductible, which is $240 in 2024. After that, Part B will pick up 80% of the prescription cost. You’ll be responsible for the other 20% unless you have a Medigap plan. Your costs will also be different if you are enrolled in a Medicare Advantage plan.

Medicare Part D Prescription Coverage

Medicare Part D is devoted to helping Medicare beneficiaries with their outpatient prescription costs. Although Part D isn’t mandatory, the program will penalize you if you don’t enroll as soon as you’re eligible. Part D covers prescriptions that meet the following criteria:

• Not covered by Parts A or B

• Must be approved by the FDA

• Only available by prescription

• Sold in the United States

• Used for medically-accepted reasons

• Covered on your Part D plan’s drug formulary

Sounds like a lot of rules, right? It is, but even despite that list, Part D offers coverage for a large number of medications. Plus, Medicare requires all Part D plans to include certain drugs in the formularies. Every Part D plan must include coverage for anti-psychotic drugs, anti-seizure drugs, anticonvulsants, antidepressants, self-administered immunosuppressive drugs, and drugs used to treat HIV and AIDs.

Drugs not covered by Part D include those for weight loss or weight gain, over-the-counter medications, hair growth supplements, and vitamins and minerals.

Medicare Advantage Prescription Coverage

Some Medicare beneficiaries choose to enroll in Medicare Advantage rather than Original Medicare. Every Medicare Advantage plan must include at least as much coverage as Parts A and B offer, though the cost-sharing requirements are usually different. 

Many Medicare Advantage plans also include drug coverage. You’ll see these plans abbreviated as MAPD plans. Drug coverage within these plans works the same as a stand-alone Part D plan, but remember to consult the drug formulary before enrolling.