Does Medicare Cover Shots for My Condition?

Toni,

I am turning 65 in February and my health plan has a $6,000 deductible which I meet every year due to shots given in my eyes for macular degeneration which are more than $2500 per injection. I also receive weekly allergy shots from another doctor. Does spay for injections given at a doctor’s office?

My other concern is how will Medicare pay for this charge. Looking forward to your answer.

Sherry from Lake Charles, LA

Sherry,

Most Americans don’t know what’s covered under Medicare Part B, which is the medical part of Medicare, so you aren’t alone. Let’s discuss it a little further.

What Does Part B Cover?

The “Medicare and You” handbook states that Medicare Part B helps cover medically necessary doctors’ services, outpatient care, home health services, durable medical equipment, and other medical services.”

Sherry, you mentioned that you have a concern about whether Medicare will cover expensive macular degeneration injections for your eyes and allergy shots. If these procedures are medically necessary, then Medicare will pay for those procedures under Medicare Part B.

What Does “Medically Necessary” Mean?

The term “medically necessary,” as defined by Medicare, means “healthcare services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms that meet accepted standards of medicine.”

Medicare covers medically necessary doctor services (including outpatient services and some doctor services you get when you are a hospital inpatient) and covers preventative services. Medicare also covers services you get from other healthcare providers like physician assistants, nurse practitioners, social workers, physical therapists, and psychologists.

What’s the Deductible in 2024?

For 2024, the Medicare Part B medical/doctor deductible is $240 with Medicare paying 80% of the Medicare-approved amount and you (the beneficiary) paying 20% of the approved amount. (Chapter 2 of my book “Medicare Survival Guide Advanced” explains Original Medicare Part A and B in detail.)

Additionally, during Medicare consultation, the Toni Says team always verifies that your prescriptions—including doctor office visits—are also covered on your Medicare Part D plan.

2024 Medicare Part D Costs Are:

• The initial Deductible is $545.
• The initial Coverage Limit is $5,030 when the “Donut Hole” begins.
• Donut Hole (Coverage Gap) begins once the Medicare beneficiary reaches the Medicare Part D plan’s initial coverage limit of $5,030 and ends when a total of $8,000 is out-of-pocket. The Medicare beneficiary will then be responsible for only 25% of the prescription drug cost while 70% is paid by the brand name/generic drug manufacturer and 5% is paid by the enrolled Medicare Part D plan until the Donut Hole ends when the $8,000 exit point is reached.
• Catastrophic Coverage of $0 out of pocket begins January 1, 2024: when a Medicare recipient enters Catastrophic Coverage. Medicare will pick up all costs of the prescriptions whether brand name or generic and those with a Medicare Part D plan pay $0.

On January 1 of each year, the process starts all over again with a new Medicare Prescription Drug plan and different costs, deductibles, and a new Donut Hole. 

How Can I Pay for the 20% Out of Pocket?

To help pay for the 20% 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. 

The Medicare handbook states the following: “If you are in a Medicare Advantage Plan (like an HMO or PPO) or have other insurance, your costs may be different. Make sure to contact your plan to find out the costs!

On page 39 of the 2024 “Medicare & You” handbook, it states: “If you haven’t received services from your doctor or group practice in the last 3 years, they may consider you a new patient. Check with the doctor or group practice to find out if they are accepting new patients.” As you approach Medicare age, make sure to visit your doctor regularly to find out!

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