Medicare covers bismuth subsalicylate only under specific conditions, and the coverage depends on which part of Medicare you have and how the medication is prescribed.
Bismuth subsalicylate is the active ingredient in Pepto-Bismol and similar over-the-counter stomach remedies. Medicare Part B covers it only when a doctor prescribes it as a compounded medication — meaning a pharmacist mixes it specially for you — or when it is part of a prescription combination product. If you buy bismuth subsalicylate off the shelf at a drugstore without a prescription, Medicare will not pay for it, even if you have a prescription drug plan.
Medicare Part D (prescription drug coverage) does not cover over-the-counter medications unless your doctor writes a prescription for them. Even then, coverage varies by plan. Some Part D plans include bismuth subsalicylate on their formulary (the list of drugs they cover), and others do not. Your specific plan's formulary determines what you pay.
Key Takeaways
- Over-the-counter bismuth subsalicylate bought at a store is not covered by any part of Medicare, even if you have Part D.
- Medicare Part D may cover bismuth subsalicylate if your doctor writes a prescription for it, but only if your specific plan includes it on the formulary.
- Medicare Part B covers compounded bismuth subsalicylate prescribed by a doctor, though this is less common than over-the-counter use.
- You can check your plan's formulary on Medicare.gov or by calling your plan's customer service number to learn whether bismuth subsalicylate is covered.
How Medicare Part D Covers Bismuth Subsalicylate
Part D is the prescription drug coverage that comes with Original Medicare or is bundled into Medicare Advantage plans. To get Part D coverage of bismuth subsalicylate, your doctor must write a prescription for it. The prescription tells the pharmacy that the medication is medically necessary for your condition, not just something you are buying for occasional heartburn or upset stomach.
Once you have a prescription, your Part D plan will check its formulary. If bismuth subsalicylate is on the list, you will pay your plan's copay or coinsurance for that drug. If it is not on the formulary, your plan will not cover it, and you will pay the full retail price. Some plans place bismuth subsalicylate in a higher cost tier, meaning you pay more than you would for other stomach medications.
Different Part D plans have different formularies. Two people with different plans may have very different coverage for the same medication. This is why checking your own plan's formulary before filling a prescription matters.
When Medicare Part B Covers Bismuth Subsalicylate
Medicare Part B covers compounded medications — those mixed by a pharmacist to your doctor's exact specifications — when medically necessary. If your doctor prescribes a compounded bismuth subsalicylate preparation because an off-the-shelf version will not work for you (for example, if you have an allergy to a filler ingredient), Part B may cover it.
Compounded medications are less common than standard prescriptions and usually cost more. Part B covers 80 percent of the cost after you meet your deductible, and you pay the remaining 20 percent. This is different from Part D, where you typically pay a flat copay or a percentage of the cost depending on the drug's tier.
How to Check Your Plan's Formulary
The fastest way to find out whether your Part D plan covers bismuth subsalicylate is to look up your plan's formulary on Medicare.gov. Go to the Medicare Plan Finder tool, enter your information, and select your plan. The formulary will show you every drug your plan covers, the tier it is in, and what you will pay.
You can also call your plan's customer service number, which is on the back of your insurance card. Tell them you want to know whether bismuth subsalicylate is covered and what your copay or coinsurance would be. They can also tell you whether your doctor needs to get prior authorization — permission from the plan before filling the prescription — though this is uncommon for bismuth subsalicylate.
If your plan does not cover bismuth subsalicylate, ask your doctor whether an alternative stomach medication on your formulary might work for you. Many plans cover other antacids or anti-diarrheal drugs at a lower cost.
What Happens If Your Plan Does Not Cover It
If bismuth subsalicylate is not on your Part D formulary, you have several options. You can pay out of pocket for the medication at the retail price, which is usually between $5 and $15 for a bottle of Pepto-Bismol or a generic equivalent. You can ask your doctor to prescribe a different medication that your plan does cover. Or you can wait until the next open enrollment period (October 15 to December 7 each year) and switch to a different Part D plan that does cover bismuth subsalicylate.
If you switch plans specifically because of a medication you need, make sure the new plan's formulary actually includes it before you enroll. Formularies change every year, so a plan that covers bismuth subsalicylate this year may not cover it next year.
Over-the-Counter vs. Prescription Coverage
The key difference is that Medicare will not pay for any over-the-counter medication you buy without a prescription, no matter which part of Medicare you have. This includes bismuth subsalicylate. If you walk into a drugstore and buy a bottle of Pepto-Bismol with your own money, Medicare sees nothing to cover.
However, if your doctor writes a prescription for bismuth subsalicylate and sends it to the pharmacy, the situation changes. Now it is a prescribed medication, and Part D may cover it depending on your plan. The medication itself is the same — the difference is the prescription and your plan's decision to include it.
Many people do not realize this distinction and assume that because a medication is available over the counter, Medicare will not cover it even with a prescription. That is not always true. Talk to your doctor if you use bismuth subsalicylate regularly. A prescription might lower your out-of-pocket cost.
Frequently Asked Questions
Can I get Medicare to cover Pepto-Bismol if I buy it at the store?
No. Over-the-counter Pepto-Bismol and other bismuth subsalicylate products bought without a prescription are never covered by Medicare. If you want coverage, your doctor must write a prescription for bismuth subsalicylate, and your Part D plan must include it on the formulary.
Do I need my doctor's permission to get bismuth subsalicylate covered?
Yes. Your doctor must write a prescription for it. Without a prescription, it is an over-the-counter purchase that Medicare will not cover. Once you have a prescription, your Part D plan will check whether it is on the formulary.
What if my doctor prescribes it but my plan does not cover it?
You can pay the retail price out of pocket, ask your doctor to prescribe a covered alternative, or switch to a different Part D plan during open enrollment if another plan covers bismuth subsalicylate. Check the new plan's formulary before you enroll to make sure it is included.
Does Medicare Advantage cover bismuth subsalicylate?
Medicare Advantage plans include Part D prescription drug coverage, so the same rules explore. Your specific plan's formulary determines coverage. Check your plan's formulary or call the plan's customer service number to find out whether bismuth subsalicylate is covered.
Will I pay more for bismuth subsalicylate if it is on a higher tier?
Yes. Part D plans organize drugs into tiers, and higher tiers mean higher copays or coinsurance. If bismuth subsalicylate is on a higher tier, you will pay more than you would for a drug on a lower tier. Your plan's customer service can tell you which tier bismuth subsalicylate is on and what your cost will be.