Does Medicare Cover Septra or Bactrim?
This article was updated on: 09/10/2018
Prescription drugs such as Septra or Bactrim are not generally covered under Original Medicare (Part A and Part B), unless you are also enrolled in a stand-alone Medicare Prescription Drug Plan or a Medicare Advantage Prescription Drug plan. If you take Septra or Bactrim and would like help paying for your medication, here’s what you should know about Medicare and prescription drug therapy.
What is Septra used for?
Septra and Bactrim are brand-name preparations of the combination of the generic drugs sulfamethoxazole and trimethoprim. This antibiotic is often prescribed to treat urinary tract infections, ear infections, bronchitis, and diarrhea.
It is also used to treat and prevent Pneumocystis pneumonia (PCP), a form of pneumonia that occurs in people with compromised immune systems, such as cancer patients, people who have had an organ transplant, and people with HIV/AIDS. In some cases, individuals are given Septra or Bactrim on a long-term basis as prophylaxis (preventive therapy) or maintenance to prevent a recurrence of PCP or other opportunistic infections.
When does Medicare cover Septra or Bactrim?
Under Original Medicare, Septra and Bactrim are generally not covered except in the following circumstances:
- If you are treated with Septra or Bactrim while an inpatient in a hospital or skilled nursing facility during a stay covered by Medicare.
- If your doctor administers Septra or Bactrim as an injection or infusion in his office or other outpatient facility such as an emergency department.
In order to get Medicare coverage for Septra or Bactrim to take at home, you typically need to be enrolled in a Medicare Part D Prescription Drug Plan that includes Septra or Bactrim in its formulary. A formulary is a list of medications a plan will pay for and the benefits available for each. It also lists any special conditions, such as prior authorization, that apply to the medication. A plan may change its formulary at any time, but it will notify you in writing before any changes take place.
Do Medicare Advantage plans cover Septra or Bactrim?
Most Medicare Advantage plans include Part D coverage for prescription drugs (known as MAPDs), especially Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). If you want coverage for prescription drugs like Septra or Bactrim and prefer the Medicare Advantage program, be sure to select a plan that includes Part D prescription drug coverage, since stand-alone Medicare Part D Prescription Drug Plans can’t be combined with most types of Medicare Advantage plans.
If you enroll in a stand-alone prescription drug plan and you have Medicare Advantage, you may be automatically removed from your Medicare Advantage plan and returned to Original Medicare.
Keep in mind that Medicare Advantage plans and Medicare Part D Prescription Drug Plans are offered by private insurance companies contracted with Medicare; as such, plan benefits, premiums, deductibles, copayments, and coinsurance amounts may vary depending on where you live and the plan you select. Not all plan types may be available in all areas. You must continue to pay your Medicare Part B premium if you enroll in Medicare Advantage, plus any additional premiums required by your plan.
If you think you want Medicare Part D coverage for prescription drugs, you should enroll in a plan as soon as you are eligible to avoid paying a late-enrollment penalty with your monthly premium for as long as you have coverage.
I’m available to help you with any questions you may have about Medicare coverage of Septra or Bactrim and other prescription medications. I can also help you find information about Medicare Advantage plans if you have a serious or chronic health condition that requires long-term therapy with Septra or Bactrim. You can request information via email or schedule a phone call at your convenience by clicking one of the links. To see a list of plans in your area that you may qualify for, click the Compare Plans or Find Plans buttons.