Does Medicare cover expensive shots given at the doctor’s office?

Toni:

I am turning 65 in February and my individual 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 $2,500 per injection. I also receive weekly allergy shots from another doctor. Does Medicare pay for injections given at a doctor’s office?

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

--Sherry from Lake Charles, La.

Sherry:

Most Americans do not know what is covered under Medicare Part B, which is the medical part of Medicare, so you are not alone.

In the Medicare and You handbook under “What does Part B cover,” it states that Medicare Part B “helps cover medically necessary doctor’s services, outpatient care, home health services, durable medical equipment, mental health services, and other medical services.”

Sherry, you mentioned that you have a concern about whether expensive macular degeneration injections for your eyes and allergy testing/allergy shots can be covered under Medicare. If these procedures are medically necessary, then Medicare will pay for those procedures under Medicare Part B. Your out-of-pocket is the current year’s Part B deductible. For 2024, the 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 Medicare Survival Guide Advanced edition explains Original Medicare Part A and B in detail.)

As defined by Medicare, “medically necessary” 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.”

Additionally, during a Medicare consultation, the Toni Says team always verifies that your prescriptions -- including doctor office visit medical injections such as your expensive macular degeneration medications -- are also covered on your Medicare Part D plan if for some reason Medicare will not allow the medical injection to be covered during an office visit.

In the handbook under “Doctor and other health care provider services,” it states that Medicare covers medically necessary doctor services (including outpatient services and some doctor services you get when you are a hospital inpatient) and covered preventive services. Medicare also covers services you get from other health care providers like physician assistants, nurse practitioners, social workers, physical therapists, and psychologists.

To help pay for the out-of-pocket costs, many Medicare beneficiaries choose a Medicare Supplement to help defray the Medicare Parts A and B deductibles and out-of-pocket charges.

The Medicare handbook states that “if you are in a Medicare Advantage Plan (like an HMO or PPO) or have other insurance, your costs may be different. Contact your plan to find out the costs.” You should 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.

Readers, be sure to visit your doctor regularly when approaching Medicare age. Page 39 of the 2024 Medicare and You handbook states: Important! 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.

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Toni King is an author and columnist on Medicare and health insurance issues. She has spent nearly 30 years as a top sales leader in the field. If you have a Medicare question, email info@tonisays.com or call 832-519-8664. Toni’s books and her newsletter are available at www.tonisays.com. Toni’s new Confused about Medicare video series is now available for purchase at www.tonisays.com, as are Toni’s Medicare Survival Guide and discounted bundle package.