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Understanding Medication Costs and Telehealth Coverage Under Medicare

 

Understanding Medication Costs and Telehealth Coverage Under Medicare

If you take a medication that must be administered in your doctor’s office, it’s important to know that your out-of-pocket costs can vary significantly depending on how the medication is billed.

How Medication Billing Works

Here’s the key difference:

  • If your prescription is filled at a pharmacy and you bring the medication to your doctor’s appointment for administration, the cost is usually covered under your Medicare Part D prescription drug plan.

  • If your doctor provides the medication directly from their office, the cost will typically be billed through Medicare Part B medical insurance.

Why Does This Matter?

The distinction is important because Medicare Part B and Part D have different cost-sharing rules, especially if you have a Medicare Advantage plan.

  • Under Part D, you typically pay a copayment or coinsurance based on your plan’s formulary tier system.

  • Under Part B, you generally pay 20% coinsurance of the Medicare-approved amount after your deductible is met.

Some Medicare Advantage plans may have additional rules, and the difference in cost-sharing can sometimes mean a large difference in what you pay out of pocket.

Common Medications That Can Be Billed Under Part B or Part D

Certain medications can be administered either at your doctor’s office or obtained at a pharmacy. Here are some examples:

  • Injectable osteoporosis medications, like Prolia or Forteo: If your doctor injects these during a visit, they are billed under Part B; if you get the medication at a pharmacy and bring it with you, it may be billed under Part D.

  • Injectable migraine treatments such as Aimovig or Emgality: These can be administered in-office (Part B) or self-injected after being filled at a pharmacy (Part D).

  • Infused rheumatoid arthritis medications, like Remicade or Orencia: Typically given in-office and billed under Part B.

  • Some cancer drugs administered in infusion centers are billed under Part B.

  • Vaccines such as the flu shot, pneumonia vaccine, and COVID-19 vaccines are usually covered under Part B when given in a doctor’s office.

Knowing where your medication is billed helps you anticipate costs and avoid surprises.

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