Dear Pauline,

As you likely know, after getting a kidney transplant, a kidney recipient will need to take immunosuppressant drugs for the rest of their life to prevent their body from rejecting the donor organ. Medicare covers these drugs differently depending on the circumstances:

Time-limited Part B coverage
If someone receives a kidney transplant in a Medicare-approved facility, Medicare Part B will cover their immunosuppressant drugs for 36 months after their hospital departure if:

• They had Part A at the time of the transplant
• They have Part B when getting their prescription filled
• And, they are only eligible for ESRD Medicare
  • If the kidney transplant was successful, Medicare coverage will end 36 months after the month of the transplant

Note: If someone did not have Medicare at the time of their transplant, they can enroll retroactively in Part A within a year of their transplant.

Part B coverage for the rest of one’s life
If someone receives a kidney transplant in a Medicare-approved facility, Part B will cover their immunosuppressants for the rest of their life if:

• They had Part A at the time of the transplant
• They had Part B when getting their prescription filled
• And, they qualify for Medicare based on age or disability

Part B-ID coverage
If someone’s ESRD Medicare benefits end 36 months after their transplant, they may qualify for Medicare’s new Part B-ID coverage of immunosuppressants if they:

• Qualify for Part B coverage of immunosuppressants prior to losing ESRD Medicare
• Do not have Medicaid 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. 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 someone access to Part A.

Part D coverage
If someone does not have Part A when they receive a transplant, their immunosuppressants will be covered by Part D when they are enrolled in Medicare. Part D coverage for this type of drug typically means higher costs and additional restrictions, such as having to go to specific in-network pharmacies for drugs, as compared to coverage under Part B.

All Part D formularies must include immunosuppressant drugs. Step therapy is not allowed once someone is stabilized on their immunosuppressant drug. However, prior authorization can apply. This might mean a Part D plan will verify that, for example, Part B will not cover the drugs before providing coverage. It’s good to look for plans that have the fewest coverage restrictions and where one’s pharmacy is in-network and has preferred cost-sharing available to minimize costs and disruptions.

I hope this helps. I’m wishing your mom a successful transplant and speedy recovery!

-Marci