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 (ranibizumab) for macular degeneration. The cost is more than $2,500 per shot, given at the doctor’s office. I also have allergy shots each week from another doctor.
My concern is how will Medicare pay for these charges. Look forward to your answer.
-Tabitha, from Sugar Land, Texas
Great question. 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?” section, it states that Part B “helps cover medically necessary doctor’s services, outpatient care, home health services, durable medical equipment, and other medical services.”
Tabitha, you mentioned that you have a concern about whether the 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 cost 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, including office-visit 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.
“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 & other health care provider services,” it states that “Medicare covers medically necessary doctor services (including outpatient services and some inpatient hospital doctor services) and covered preventative services. Medicare also covers services you get from other health care providers, like physician assistants, nurse practitioners, clinical nurse specialists, clinical social workers, physical therapists, occupational therapists, speech-language pathologists and clinical psychologists.” The 2023 Part B medical/doctor deductible is $226, with Medicare paying 80% of the Medicare approved amount and you (the Medicare beneficiary) paying 20% of the Medicare approved amount after the deductible is met.
Many enrollees chose Medicare Supplement Insurance (Medigap) to defray the Medicare Parts A and B deductibles and 20% out-of-pocket charges. With a Medicare Supplement, Tabitha, you can have low (or even zero) out-of-pocket costs for Medicare approved amounts, depending on which plan you choose.
If you are in a Medicare Advantage Plan (like an HMO or PPO) or have other insurance, your costs may be different. You should always contact your plan to find out the costs. You will want to 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 and columnist on Medicare and health insurance issues. She spent more than 27 years as a top sales leader in the field. For a Medicare checkup, email: firstname.lastname@example.org or call 832-519-8664. You can now visit www.seniorresource.com/medicare-moments to listen to her Medicare Moments podcasts and get other information for boomers/seniors.