Medicare's coverage of methoxsalen depends on the type of Medicare you have and how the drug is given to you

Methoxsalen is a medication used to treat certain skin conditions, most commonly psoriasis and vitiligo. It works by making your skin more sensitive to ultraviolet (UV) light, and is usually given as a pill taken before UV therapy or as a topical cream applied to the skin.

Medicare Part B covers methoxsalen when it is administered in a hospital outpatient setting or a doctor's office as part of photochemotherapy (light therapy treatment). Medicare Part D, which covers prescription drugs, may cover methoxsalen pills if you take them at home, but coverage varies by plan and formulary.

The key difference is where and how you receive the drug. If your dermatologist gives it to you during an office visit before light therapy, Part B typically pays. If you pick up a prescription at a pharmacy to use at home, Part D coverage depends on your specific plan.

Key Takeaways

  • Medicare Part B covers methoxsalen when administered in a doctor's office or hospital outpatient setting as part of photochemotherapy treatment.
  • Medicare Part D may cover methoxsalen pills taken at home, but you need to check your specific plan's formulary to know for certain.
  • Your out-of-pocket costs depend on whether you have Original Medicare, a Medigap plan, or a Medicare Advantage plan.
  • Before starting methoxsalen treatment, ask your dermatologist whether the drug and the light therapy sessions are covered under your Medicare plan.

How Medicare Part B covers methoxsalen in medical settings

When methoxsalen is given to you by a healthcare provider in a clinical setting, Medicare Part B treats it as a covered service. This includes methoxsalen administered in a dermatologist's office, a hospital outpatient department, or an ambulatory surgical center before you receive photochemotherapy.

Part B covers the drug itself, the administration of the drug, and the light therapy that follows. You pay your Part B deductible (which resets each year) and then 20 percent of the Medicare-approved amount for the service. If you have a Medigap plan, it may cover some or all of that 20 percent coinsurance.

The dermatologist's office will bill Medicare directly for the methoxsalen and the phototherapy session as a single treatment. You do not need to obtain a separate prescription or fill it at a pharmacy in this scenario.

How Medicare Part D covers methoxsalen pills at home

If your doctor prescribes methoxsalen pills for you to take at home before home-based light therapy or for other uses, coverage falls under Medicare Part D. Part D is optional prescription drug coverage, and not all Part D plans cover methoxsalen.

Each Part D plan maintains a formulary — a list of covered drugs. Methoxsalen may be on your plan's formulary, on it with restrictions (such as requiring prior authorization from your doctor), or not covered at all. You can check your plan's formulary on your plan's website or by calling the plan's customer service number.

If methoxsalen is covered, you typically pay a copay or coinsurance at the pharmacy. The amount depends on which tier the drug is placed on in your plan's formulary. Methoxsalen is not a commonly used drug, so some plans may not include it or may require your doctor to request prior authorization before the pharmacy can fill it.

What to do if your plan does not cover methoxsalen

If your Part D plan does not cover methoxsalen or requires prior authorization, your dermatologist can request an exception or appeal on your behalf. This is called a formulary exception request. Your doctor explains the medical reason why methoxsalen is necessary for your condition and why alternatives would not work as well.

Medicare requires Part D plans to respond to exception requests within 72 hours. If the plan denies the request, you and your doctor can appeal the decision. This process can take longer, so it is worth starting it as soon as you know methoxsalen is the recommended treatment.

Another option is to ask your dermatologist whether the treatment can be done in an office setting instead. If methoxsalen is administered in the office with phototherapy, Part B covers it without the formulary restrictions that Part D plans impose.

Medicare Advantage plans and methoxsalen coverage

If you have a Medicare Advantage plan (Part C), your coverage for methoxsalen depends on the specific plan you chose. Medicare Advantage plans must cover at least what Original Medicare covers, but they often have different rules about where you can receive care and whether prior authorization is required.

Some Medicare Advantage plans contract with specific dermatologists or dermatology centers. If you want methoxsalen treatment, you may need to use an in-network provider or the plan may not cover the service at all. Check your plan's provider directory and call the plan to confirm coverage before scheduling treatment.

Medicare Advantage plans also include prescription drug coverage built in, so if you need methoxsalen pills, the plan's formulary applies. The copay or coinsurance may be different from what a standalone Part D plan would charge.

Cost considerations and what to ask your doctor

The out-of-pocket cost for methoxsalen varies widely depending on your coverage type. With Original Medicare and Part B, you pay 20 percent of the approved amount after your deductible. With Part D, you pay the copay or coinsurance set by your plan. With Medicare Advantage, costs depend on your plan's design.

Before your first appointment, ask your dermatologist's office to verify coverage with Medicare or your plan. Provide your Medicare number and ask specifically whether methoxsalen and phototherapy are covered in their office setting. If you are prescribed methoxsalen pills, ask the office to check your Part D formulary before you fill the prescription.

Ask whether there are any prior authorization requirements and, if so, whether the office will handle the request. Also ask about the total number of sessions you will need and what the estimated out-of-pocket cost will be for the full course of treatment.

When to contact Medicare or your plan directly

Contact Medicare (1-800-MEDICARE) if you have Original Medicare and want to confirm that methoxsalen and phototherapy are covered services. Have your Medicare number ready and be specific about the treatment your dermatologist recommended.

If you have a Medicare Advantage plan or Part D coverage, call the plan's customer service number on the back of your insurance card. Ask whether methoxsalen is covered, what your out-of-pocket cost will be, and whether prior authorization is needed. Ask the representative to note your call in case there is a dispute later.

If your plan denies coverage and you believe it should be covered, you have the right to appeal. Ask the plan for its appeal process in writing and follow the steps carefully, including any important date.

Frequently Asked Questions

Does Medicare cover the light therapy sessions that go with methoxsalen?

Yes. When methoxsalen is given in a medical setting, the phototherapy sessions are covered as part of the same treatment under Medicare Part B. If you receive methoxsalen pills at home and do light therapy at home, coverage depends on whether your setup qualifies as a covered medical service, which is rare.

What if my dermatologist's office is out of network for my Medicare Advantage plan?

Out-of-network care is usually not covered by Medicare Advantage plans, or you pay a much higher cost. Call your plan before scheduling with an out-of-network dermatologist. If no in-network dermatologist offers methoxsalen treatment, your plan may allow an exception, but you must request it in advance.

Can I use a GoodRx coupon or discount card if Medicare does not cover methoxsalen?

Yes. If your Part D plan does not cover methoxsalen or if you do not have Part D, you can use a discount card like GoodRx at the pharmacy. Compare the discount price to what you would pay out of pocket, and ask your pharmacist which option is cheaper for your specific prescription.

Will I need prior authorization for methoxsalen in my dermatologist's office?

Probably not. Methoxsalen administered in a medical office under Part B usually does not require prior authorization. However, some Medicare Advantage plans do require it, so call your plan before your appointment to be sure.

What happens if I start methoxsalen treatment and then find out it is not covered?

Contact your plan or Medicare when ready. If you received the treatment in good faith and the plan should have covered it, you may not be responsible for the bill. If you received it knowing it was not covered, you are responsible. This is why verifying coverage before treatment starts is important.