Will Medicare cover injections given in a doctor’s office?

Dear Toni: I am turning 65 in March and my individual health plan has a $4,000 deductible, which I meet every year due to shots of Lucentis for macular degeneration. The cost is more than $2,500 per shot, given at the doctor’s office. I also have allergy shots each week from another doctor. My concern is how will Medicare pay for these charges. — Tabitha, Sugar Land, Texas

Dear Tabitha: Many Americans do not realize what is covered under Medicare Part B, which is the medical part of Medicare.

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

You have a concern about whether the macular degeneration injections for your eyes, and the allergy testing and shots, can be covered under Medicare Part B. If these procedures are medically necessary, then Medicare will pay for them. Your out-of-pocket cost is the current year’s Part B deductible.

“Medically necessary,” as defined by Medicare, 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.”

In the handbook under “Doctor &other health care provider services,” it states that “Medicare covers medically necessary doctor services (including outpatient services and some inpatient hospital doctor services) and covered preventative services. Medicare also covers services you get from other health care providers, like physician assistants, nurse practitioners, clinical nurse specialists, clinical social workers, physical therapists, occupational therapists, speech-language pathologists and clinical psychologists.”

The 2023 Part B medical/doctor deductible is $226, with Medicare paying 80 percent of the Medicare approved amount and the Medicare beneficiary paying 20 percent of the Medicare-approved amount after the deductible is met.

Many enrollees choose Medicare supplement insurance (Medigap) to defray the Medicare Parts A and B deductibles and 20 percent out-of-pocket charges. With a Medicare supplement, you can have low (or even zero) out-of-pocket costs for Medicare-approved amounts, depending on which plan you choose.

Toni King is an author and columnist on Medicare and health insurance issues. For a Medicare checkup, email info@tonisays.com or call 832-519-8664.