Why does Original Medicare not include most prescription drug coverage?

Mike Olmos by Mike Olmos | Licensed since 2010
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This article was updated on: 10/06/2018

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People age 45 and older take an average of four prescription medications daily, according to research from AARP conducted between 1986 and 2002. If you’re new to Medicare, you might be surprised to learn that Original Medicare (Part A and Part B) doesn’t include prescription drug coverage for most medications you take at home. Prescription medication makes up a huge percentage of health care costs for Medicare beneficiaries. According to the Kaiser Family Foundation in 2017, prescription drugs account for $1 out of every $6 in Medicare spending.

According to an article titled “A Political History of Medicare and Prescription Drug Coverage” in the U.S. National Library of Medicine (NLM), prescription drug coverage has usually been tied to broader proposals for Medicare reform. The answer to what Medicare covers is a political one; balancing maximum benefits for Medicare beneficiaries while minimizing costs to taxpayers. Action to add prescription drug coverage to the Medicare program has been hampered by:

  • Divided government
  • Federal budget deficits
  • Ideological conflict between the role of the traditional Medicare program and the role of private insurance companies

What kinds of prescription drugs does Original Medicare cover?

Original Medicare generally covers prescription drugs in certain circumstances. Medicare Part A (hospital insurance) may offer prescription drug coverage for medications you take as an inpatient in a hospital. Medicare Part B (medical insurance) may offer prescription drug coverage for certain types of medications you take in a doctor’s office or hospital outpatient setting. According to NML, this provision was designed to prevent a physician from hospitalizing a patient just to get a needed medication covered. Examples of medications typically covered by Original Medicare Part B include:

  • Medications used with an item of durable medical equipment, such as an infusion pump or nebulizer
  • Injectable and infused medications
  • Vaccinations
  • Oral cancer medications
  • Immunosuppressive medications for transplant patients
  • Oral end-stage renal disease medications

How can I get prescription drug coverage if I have Medicare?

If you need prescription drug coverage for medications you take at home, you generally need Medicare Part D coverage. Medicare Part D prescription drug coverage is voluntary and may help reduce your out of pocket spending on prescription drugs. You can get Medicare Part D coverage through one of two ways:

  • A Medicare Advantage plan with prescription drug coverage
  • A stand-alone Medicare Part D Prescription Drug Plan that goes alongside your Original Medicare coverage.

How can I get help paying for prescription drug coverage?

The Extra Help program helps Medicare beneficiaries with limited income and resources afford prescription drug coverage. Some people on Extra Help pay only a portion of Medicare prescription drug plan premiums and deductibles based on their income level. You may automatically get extra help if you:

  • Have full Medicaid coverage
  • Get help paying your Part B premiums
  • Get Supplemental Security Income (SSI) benefits)

You can also apply for Extra Help through the Social Security Administration.

Do you have more questions about Medicare prescription drug coverage?

If you would like to know more about Medicare coverage of prescription drugs, please feel free to reach out to me. If you prefer, you can schedule a phone call or request an email by clicking on the buttons below. You can also find out about plan options in your area by clicking the Compare Plans button.

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