Does Medicare Cover Immunosuppressive Drugs?

Are Immunosuppressive Drugs Covered by Medicare?

Immunosuppressive drugs are covered by Medicare for various medical reasons, such as:

• To stop the body from rejecting donor organs
• To treat autoimmune conditions, such as:
  • Lupus
  • Multiple sclerosis
  • Rheumatoid arthritis
  • Psoriasis
  • Crohn’s disease
  • Alopecia areata

There are several types of immunosuppressive drugs. Some are taken orally, and others are given via infusion or injection. You may need to take one or more every day.

Medicare Part A coverage

Medicare Part A is the part of Original Medicare that covers inpatient services. If you have Part A it will cover the cost of immunosuppressive drugs given during a hospital stay.

If you are in the hospital for a donor organ, Part A will cover the cost of immunosuppressants you are given during your transplant. These powerful anti-rejection medications are known as induction drugs.

Medicare Part B coverage

Medicare Part B is the part of Original Medicare that covers outpatient services. Part B covers immunosuppressive drugs differently for different populations of Medicare beneficiaries:

If you have Medicare because you have end-stage renal disease (ESRD)

If you qualify for Medicare only because you have ESRD, Medicare Part B will cover the cost of immunosuppressive drugs after you get a kidney transplant. This coverage will end 36 months after you leave the hospital. To ensure eligibility, your procedure must take place at a Medicare-approved facility.

If you have Medicare because of age or disability

If you qualify for Medicare due to age or disability, Part B will cover the cost of immunosuppressive medications for the rest of your life, provided these criteria are met:

• You had an organ transplant.
• You had Part A at the time of the procedure.
• The transplant was done at a Medicare-approved facility.

Medicare Advantage coverage

Medicare Advantage (Part C) plans must cover at least as much as Original Medicare (Part A and Part B). If you have a Medicare Advantage plan, it will cover immunosuppressive medications after an organ transplant, provided you meet the eligibility requirements established by Medicare Parts A and B.

You may also need to meet certain requirements as outlined by your plan. These may include:

• Preauthorization by the plan.
• Confirmation by an in-network, Medicare-approved doctor of a specific diagnosis, prior to transplant.

If you use immunosuppressive drugs to treat an autoimmune condition, the prescription drug portion of your Medicare Advantage plan will cover their cost, provided it includes a Part D benefit.

Part D coverage

Medicare Part D is prescription drug coverage. It is not automatically included in Original Medicare and needs to be purchased as a separate plan.

Every Part D prescription drug plan has a formulary that includes immunosuppressive drug coverage. The specific medications included and their cost will vary from plan to plan.

Medicare only pays for prescriptions filled at a Medicare-approved pharmacy.

Part D covers the cost of immunosuppressive medication prescribed to treat an autoimmune condition. It also covers the cost of medications for medical reasons that warrant their need temporarily, such as having a severe respiratory infection, or COVID-19.

If you didn’t have Medicare Part A at the time you received an organ transplant, it is Part D and not Part B that will cover the cost of immunosuppressive medications. In some instances, these drugs may cost more under Part D than they would under Part B.