Question:
Question from Christina: I was prescribed Remicade infusions and was told they will be covered by Medicare Part B and not my Part D prescription drug plan. Can you explain this please?
Answer:
Answer: It’s very important to understand the difference between Part B and Part D prescription medications. It’s also very important to know how Medicare Supplements and Advantage Plans differ when it comes to covering Part B drugs.
Any drug that’s administered in an outpatient setting such as a physician’s office or medical facility is considered a Part B medication. Part B drugs are almost always infused or injected.
Some of the most common diagnoses that people need Part B drugs to treat are cancer; macular degeneration; Autoimmune Diseases such as rheumatoid arthritis, psoriasis, and Crohn’s; osteopetrosis; and End Stage Renal Disease. Remicade, which Chistina mentioned, is one of the most widely prescribed Part B drugs. Others are Prolia, Entyvio, and Eylea. Chemotherapy delivered via infusion is also a Part B medication.
Part D is prescription drug insurance that almost everyone on Medicare must have. Part D drugs are covered by that insurance and are prescription medications purchased from a retail or mail order pharmacy that are self-administered. Some people get Part D from an Advantage Plan HMO or PPO while those who have Supplements get theirs from a separate policy known as Stand Alone Part D.
There was a huge development that went into effect in 2025 and established a limit on what anyone who has a Part D plan from either source can pay out of pocket for covered medications in a calendar year. That cap started at $2,000, is currently set at $2,100, and will be increased to $2,400 in 2027. Once the limit is reached, all covered Part D drugs are provided at no cost for the remainder of the year.
However, that cap DOES NOT apply to Part B drugs. Original Medicare covers all Part B services, including Part B medications, at 80% and there is no limit to how much someone can be billed in a calendar year for the other 20%. Most Part B drugs are extremely expensive and the 20% that Medicare doesn’t pay for Part B medications can be hundreds, even thousands of dollars every time they’re administered. Almost everyone who chooses to remain with Original Medicare as their primary insurance buys a Supplement policy, aka Medigap, that picks up that 20%. Therefore, those who have Supplements pay $0 for Part B drugs.
However, Part B drugs are not fully covered by Advantage Plan HMOs and PPOs, which more than half of everyone on Medicare now has. Advantage Plans cover 80% of the cost of Part B drugs, leaving those on HMOs and PPOs to pay the other 20%, up to their annual health services Maximum Out of Pocket (MOOP) which can be as high as $9,250 in 2026!
This is rarely explained or disclosed to people prior purchasing an Advantage Plan. And once a Part B drug is needed, in most states, there is almost no chance for someone to move from an Advantage Plan to a Supplement. In addition, there isn’t a single Advantage Plan available that covers more than 80% of Part B drugs, you cannot have both an Advantage Plan and a Supplement at the same time, nor is there any other policy that can be purchased to cover the 20% for Part B drugs Advantage Plans don’t pay.
Be advised there are also a few exceptions when self-administered drugs are covered by Part B and not D. Anti-rejection medications that those who have had organ transplants take, insulin used in a pump, and a limited number of oral chemotherapy meds are all considered Part B drugs instead of Part D. This is good news for those with Supplements because they’re provided at zero cost. However, it’s bad news for those on Advantage Plans who are charged 20% of the full billable amount, up to their higher health cost MOOP instead of the lower Part D out of pocket limit.
With any questions regarding coverage for Part B versus Part D drugs, or if you would like to make an appointment for a no-cost consultation, give us a call 724-603-3403, or email me personally, Aaron@GetYourBestPlan.com.