Kathy enrolled in Medicare at age 65 and signed up for a Medigap Plan G (Medicare supplement insurance) and a Part D prescription drug plan. Three months later, she was diagnosed with cancer and fears she may need chemotherapy.
Kathy told me that, when checking the plan details page on the Medicare Plan Finder, she discovered her drug plan does not cover chemotherapy. Needless to say, she was very concerned and scared about the future.
It is indeed true that Part D drug plans do not cover chemotherapy or other drugs that are usually administered in a doctor’s office or hospital outpatient setting.
But Medicare Part B does cover chemotherapy.
Part B, medical insurance, is responsible for covering these treatments. If Kathy needs chemotherapy, she will present her Medicare and Medicare supplement cards. The healthcare provider will submit the claim to Medicare. With Plan G, Kathy will be responsible for the Part B deductible, $233 in 2022. After meeting the deductible, Part B will cover 80% of the costs and her Medigap plan will pay the remaining 20%. Kathy would not have any more bills to pay for her treatments.
The Medicare Plan Finder notes that Medicare Advantage plans do cover chemotherapy.
That’s because these plans must provide the same medically necessary services that Part B covers, but each plan determines its own coverage rules and cost sharing. Most Medicare Advantage plans require “advanced plan approval” or prior authorization of chemotherapy. The great majority of plans charge a 20% coinsurance for treatment.
Besides chemotherapy, some of the other drugs that Part B covers include:
- Annual flu shots
- Pneumonia vaccinations
- COVID-19 vaccination and boosters
- Injectable and infused drugs (generally cannot be self-administered)
- Immunosuppressive drugs
- Injectable osteoporosis drugs
- Parenteral and enteral nutrition (intravenous and tube feeding), and
- Insulin used with insulin pumps.
Just as with so many things in Medicare, drug coverage is confusing. If you have concerns, check with your healthcare provider or pharmacist (your own or one with your plan). You can check medicare.gov or try calling (800) MEDICARE ((800) 633-4227). And rest assured, if you need chemotherapy, the treatments will be covered and your additional coverage (a Medigap policy or Medicare Advantage plan) determines how much you pay.