Question: I recently filled my nebulizer medication at the pharmacy and had to pay full price. Why did that happen this time?

Answer: Usually when individuals ask about medication coverage the answer has something to do with Medicare Part D-Prescription Drug Coverage. This medication question is actually a Medicare Part B answer.

Medications are covered under Medicare Part B in situations where the medication is administered by a machine, like a nebulizer, or when getting the medication via IV or infusion, like Chemotherapy or Remicade. This coverage of medications is less common than the medications that most of us take on a regular basis.

To speak to your specific nebulizer question. Most of us will fill our medications at the local pharmacy or mail order. Most of those medications are billed to our prescription drug benefit (Medicare Part D when you have Medicare). When filling medications used in a nebulizer you have the choice of filling them at your local pharmacy or getting them from the company who sold you the nebulizer. The nebulizer itself is a Medicare Part B Durable Medical Equipment (DME). The medications that go into the nebulizer to help you breath are also billed to Medicare Part B. Both the machine and the medications to be used with it, can be purchased from the company that provided the machine.

When filling your nebulizer medications at the local pharmacy, the pharmacy may incorrectly bill those medications to your Medicare Part D coverage. This claim may be denied, or paid at an incorrect amount. The local pharmacy defaults to the Medicare Part D coverage because the vast majority of medications are filled under that benefit.

For nebulizer medications the pharmacy must instead input your Medicare Part B information and any secondary insurance you may have. You can determine what insurance the pharmacy has billed, by looking at your receipt and reviewing the insurance coverage listed. For a medication used in a nebulizer, a receipt listing your Part D plan is incorrect. If the receipt listing Original Medicare as the payer, that is accurate and billed to the secondary insurance. If Medicare Part B is billed, but your Supplemental Insurance if not billed, then you are required to pay the deductible and the 20% left behind. In this situation your secondary insurance can reimburse you once the claim is processed. You can insist the pharmacy bill your secondary coverage. Sometimes pharmacies find the process difficult and not supported by their computer system, so do not seem to handle this situation smoothly.

To determine who paid the claim, review your monthly Medicare Part D report and your Explanation of Benefits that are mailed, but this is usually weeks or even months later.

When medications are billed to Medicare Part B it is important to remember how Medicare Part B pays for claims. Medicare Part B has an annual deductible of $233 and pays 80% all year long after that. The annual deductible ($233) and the 20% goes to your secondary insurance or you pay. Many older individuals have Medicare Supplement Plans that pays the deductible and the 20% that Medicare doesn’t pay, so their nebulizer medications are fully covered by their insurance. If you enrolled in Medicare after January 1, 2020, and you have Medicare and a Medicare Supplement Plan, you have the $233 deductible to pay before your Medicare and your Medicare Supplement begins to pay on your Part B claims.

If you have a Medicare Advantage Plan, your nebulizer and the medications are covered by the insurance, but the amount you pay for these items depends on your plan rules. If you have a Medicare Advantage Plan, the nebulizer situation may not be as difficult because the Medicare Advantage Plan covers all your claims, Part A, B & D. In this situation the Medicare Advantage Plan simply allocates the nebulizer medications to the appropriate type of coverage and then you pay the co-pay the plan indicates.

I hope this helps to straighten out the sometimes confusing nebulizer medication coverage. Wishing you days filled with deep breath moments.

Senior Life Matters is a community based program sponsored by Lutheran Jamestown. For questions, concerns or to reach Janell Sluga, GCMC, call 716-720-9797 or email SLM@lutheran-jamestown.org.