UNITED STATES—Toni: I am turning 65 in March and my individual health plan has a $4,000 deductible which I meet every year due to shots of Lucentis for Macular degeneration which is over $2500 per shot given at the doctor’s office. I also have allergy shots given each week from another doctor. Does Medicare pay for that?
My concern is how will Medicare pay for this charge. Look forward to your answer. Tabitha from Sugar Land area.
Great question, Tabitha: Most Americans do not realize what is covered under Medicare Part B, which is the medical part of Medicare.
In the Medicare and You handbook, under the “What does Part B cover?” It states that Part B “helps to cover medically necessary doctors’ services, outpatient care, home health services, durable medical equipment, and other medical services.”
Tabitha, you mentioned that you have a concern about whether expensive macular degeneration injections for your eyes and the allergy testing, and shots can be covered under Medicare Part B. If these procedures are medically necessary, then Medicare will pay for those procedures. Your out of pocket is the current year’s Part B deductible. (Chapter 2 of my Medicare Survival Guide Advanced edition explains Original Medicare Part A and B in detail.)
During a Toni Says® Medicare consultation, we always verify that your prescriptions included office visits medical injections such as your expensive macular degeneration medications are covered on your Medicare Part D plan if Medicare will not allow the medical injection to be covered during an office visit.
“Medically necessary” as defined by Medicare means “health-care services or supplies needed to diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”
In the handbook under “Doctor and other health care provider services,” it states that “Medicare covers medically necessary doctor services (including outpatient services and some doctor services you get when you are a hospital inpatient) and covered preventative services.” Medicare also covers services you get from other health care providers like physician assistants, nurse practitioners, social workers, physical therapists, and psychologists. The 2023 Part B medical/doctor deductible is $226 with Medicare paying 80 percent of the Medicare approved amount and you (the Medicare beneficiary) paying 20 percent of the Medicare approved amount.
To help pay for the 20 percent out of pocket after the Part B deductible is met, many enrolled in Medicare chose a Medicare Supplement to help defray the Medicare Parts A and B deductibles and out of pocket charges. With a Medicare Supplement, Tabitha, you will have low or (or even zero) out of pocket for Medicare medically necessary approved amounts depending on which Medicare Supplement plan you choose.
The Medicare handbook states that “if you are in a Medicare Advantage Plan (like an HMO or PPO) or have other insurance, your costs may be different. Contact your plan to find out the costs.” Verify if your Medicare Advantage Plan will cover your injections or if it will be covered in that specific MAPD plan’s Medicare Part D plan.
Toni King is an author of Medicare Survival Guide Advanced edition and columnist of Medicare issues. For a Medicare checkup, email email@example.com or call 832-519-8664 to have your Medicare question answered. You can now visit www.seniorresource.com/medicare-moments to listen to her Medicare Moments podcast and get other information for boomer/seniors.