After you get a kidney transplant, you will need to take immunosuppressant drugs for the rest of your life to prevent your body from rejecting the donor organ. Medicare covers these drugs differently depending on your circumstances.
Time-limited Part B coverage
If you receive a kidney transplant in a Medicare-approved facility, Medicare Part B will cover your immunosuppressant drugs for 36 months after your hospital departure if:
- You had Part A at the time of your transplant
- You have Medicare Part B when getting your prescription filled
- And, you are only eligible for ESRD Medicare
- If your kidney transplant was successful, your Medicare coverage will end 36 months after the month of your transplant
Note: If you did not have Medicare when you had a transplant, you can enroll retroactively in Part A within a year of your transplant.
Part B coverage for the rest of your life
If you receive a kidney transplant in a Medicare-approved facility, Part B will cover your immunosuppressants for the rest of your life if:
- You had Part A at the time of your transplant
- You have Medicare Part B when getting your prescription filled
- And, you qualify for Medicare based on age or Disability A disability is any condition of the body or mind (impairment) that makes it more difficult for the person with the condition to do certain activities and interact with the world around them. The Social Security Administration (SSA) determines disability—and eligibility for Social Security Disability Insurance benefits (SSDI)—based on whether you can work and whether your disability is likely to be permanent. (Definition from the World Health Organization)
Part B-ID coverage
If your ESRD Medicare benefits end 36 months after your transplant, you may qualify for Part B-ID coverage of your immunosuppressants if you:
- Qualify for Part B coverage of immunosuppressants prior to losing ESRD Medicare
- Do not have Medicaid Medicaid is a federal and state program that provides health coverage for certain people with limited income and assets. or other public or private health insurance that covers immunosuppressants
Part B-ID coverage may not be the best choice if any other insurance is available to you. Part B-ID only covers immunosuppressant drugs and does not include coverage for any other Part B benefits or services. It also does not allow you access to Part A.
Part D coverage
If you do not have Part A when you receive a transplant, your immunosuppressants will be covered by Part D after your transplant. Part D coverage for this type of drug typically means higher costs and additional restrictions, such as having to go to specific in-network In-network means part of a private health plan’s network of providers. If you use doctors, hospitals, pharmacies, home health agencies, skilled nursing facilities, and durable medical equipment suppliers that are in your Medicare Advantage Plan or Part D plan’s network, you will generally pay less than if you go to out-of-network providers. pharmacies for your drugs.
All Part D formularies must include immunosuppressant drugs. Step therapy is not allowed once you are stabilized on your immunosuppressant drug. However, prior authorization can apply. This might mean your plan will verify that Part B will not cover your drugs before providing coverage. You can look for plans that have the fewest coverage restrictions Coverage restrictions, also called Utilization Management Tools or formulary restrictions, are restrictions that a health or drug plan may place on certain covered services to limit their usage. Coverage restrictions include prior authorization, quantity limits, and step therapy. and where the pharmacy you wish to use is in-network and has preferred cost-sharing Cost-sharing is the portion of medical care costs that you pay yourself, such as a copayment, coinsurance, or deductible, if you have health insurance coverage. See also: Out-of-Pocket Costs. available to minimize costs and disruptions.
Group health plan (GHP) coverage
If you have a group health plan (GHP: job-based, retiree, or COBRA coverage), your plan should cover your immunosuppressants during the 30-month coordination period. Medicare is secondary during this period. After 30 months, Medicare will become your primary insurance Primary insurance is health insurance that pays first on a claim for medical and hospital care. In most cases, Medicare is your primary insurer. See also: Secondary Insurance. , and Part D should cover your immunosuppressants.
Vitamins for dialysis patients
If you get dialysis, you typically need to take various vitamins after each session to replenish the vitamins in your blood. Medicare usually does not cover vitamin supplements, but some Part D plans may offer enhanced coverage that includes vitamins. Enhanced Part D plans are typically more expensive. Check the plan’s formulary The formulary is the list of prescription drugs covered by a Part D plan or Medicare Advantage Plan. If your drug is not on the formulary, you may have to request an exception, file an appeal, or pay out of pocket. before joining to see if your vitamins are covered.