My annual Lucentis (ranibizumab) injections for macular degeneration, which I have to get every year because my deductible for my individual health plan is $4,000, means I have to pay for health insurance out of pocket. I turn 65 in March. The price per injection, which is performed in a medical facility, is above $2,50. Another doctor gives me weekly allergy shots.
My worry is how Medicare will handle covering these costs. Am waiting for your response with eager anticipation.
Tabitha from New York
TX City of Sugar Land
Excellent inquiry. Most Americans have a misunderstanding of Medicare Part B’s medical coverage.
Part B “helps cover medically essential doctor’s services, outpatient care, home health services, durable medical equipment, and other medical services,” as stated in the Medicare and You booklet’s “What does Part B cover?” section.
Tabitha, you asked if Medicare will pay for her allergy testing and shots in addition to her macular degeneration injections. Medicare will pay for the cost of these operations if they are deemed medically essential. The amount you will be responsible for paying is the deductible for Medicare Part B this year. (Parts A and B of Original Medicare are explained in depth in Chapter 2 of my Medicare Survival Guide Advanced version.)
When you schedule a Medicare consultation with Toni Says, she will make sure that your prescriptions, including any office-visit medical injections like your costly macular degeneration drugs, are covered by your Medicare Part D coverage.
Medicare defines “medically required” as “health care services or supplies needed to diagnose or treat an ailment, accident, condition, disease or its symptoms and that meet acknowledged standards of medicine.”
Manual section “Doctor & other health care provider services” notes, “Medicare covers medically essential doctor services (including outpatient services and some inpatient hospital doctor services) and covered prevention services. Physical therapists, occupational therapists, speech-language pathologists, and clinical psychologists are just some of the various health care professionals whose services are covered by Medicare. After you’ve paid your 2023 Medicare Part B deductible of $226, Medicare will pay 80 percent of the Medicare-approved amount and you’ll be responsible for the remaining 20 percent.
Medicare Parts A and B have deductibles and 20% out-of-pocket costs that many enrollees choose Medigap to cover. If you enroll in a Medicare Supplement plan, Tabitha, you may have little to pay out of pocket for Medicare-approved services and supplies.
Medicare Advantage Plan members (like those in an HMO or PPO) and those with other insurance may have differing out-of-pocket expenses. When in doubt about whether or not something is covered by your plan, call customer service. It is important to research whether or not the injections you need are covered by your Medicare Advantage Plan or the Medicare Part D plan that your MA plan uses.