Question:
If I go to the hospital as an outpatient, what part of Medicare covers my prescription drugs?
Answer:
If you go the hospital for an outpatient procedure, your hospital visit will be covered under Part B (inpatient stays are covered under Part A). However, which part of Medicare will cover your drugs depends on why you need those medications.
All medications that you take while you are at the hospital will have to come from the hospital pharmacy. Even if you have a filled prescription, hospitals do not allow you to bring your own medications because the hospital needs to carefully manage drug interactions during your stay.
If you have Part D drug coverage, in most cases, the hospital pharmacy will not be in your plan’s network, so the hospital will not be able to bill your plan directly. The hospital will bill you and you will need to request reimbursement from your Part D plan for out-of-network coverage.
When you submit your request for reimbursement from your plan, include a letter that explains that while you usually use network pharmacies, it was not possible in this case because you were getting an outpatient procedure and had to get your medication from the hospital pharmacy. The plan is only required to reimburse you for the amount it usually pays, so you may be responsible for the difference between what the plan pays and what the hospital charges.
If you have Extra Help—a federal assistance program that helps pay for most of the costs of a Part D plan—the plan must reimburse you for the entire amount you paid for the prescription, except your Extra Help co-pay.
If you do not have Part D, but have other prescription drug insurance, such as Medicaid, employer or retiree insurance, that insurance may help cover the cost of these medications. In many cases, the hospital will be able to bill these insurers directly for the medications. If you have no prescription drug coverage, you will be responsible for the costs of the prescriptions.
