If you think you have an allergy, it’s important to determine that for a fact so you can avoid triggering a reaction and putting yourself at risk. This is especially true if you didn’t know you had an allergy and accidentally triggered a reaction. It becomes time to find out what exactly you’re allergic to. You can do so with one of several allergy tests. After you have your test, you also should begin treatment of some kind, often over-the-counter medications. Should your reaction be severe enough, it may be a good idea to consider an allergy shot.
If you’re receiving both these services without coverage, they can be quite expensive, which may push you to avoid having them done. This can leave you with questions and a lingering risk that you may trigger another severe reaction again. Medicare can help cover these costs, but coverage of allergy treatment and testing isn’t always straightforward.
Medicare Coverage of Allergy Testing
Luckily, finding out what you’re allergic to is generally covered by both Original Medicare and Medicare Advantage plans. This is because it’s considered a diagnostic test, since it’s diagnosing what you’re allergic to. Under Original Medicare, it’s usually covered by Medicare Part B, though it may be covered by Part A if you’re receiving it as part of inpatient care. Under Medicare Part B, you’ll owe 20 percent of the Medicare-approved amount, with the other 80 percent covered by Original Medicare. If you have a Medicare Advantage plan, services are generally covered the same as Original Medicare at a minimum, though some offer more coverage. This can vary from plan to plan, though.
Most commonly used allergen tests, like the common skin prick test, should be covered by your Medicare plan.
There are situations where Medicare may not cover your allergy test, though these are pretty specific. According to the Centers for Medicare & Medicaid Services (CMS) billing guidelines, allergy tests aren’t covered if they’re specific types of outdated tests (sublingual intracutaneous and subcutaneous provocative and neutralization testing, challenge ingestion food testing, and cytotoxic food tests). These tests generally have been found to be ineffective or unsafe. Most commonly used allergen tests, like the common skin prick test, should be covered by your Medicare plan.
Medicare & the Allergy Shot
Coverage becomes more complicated when it comes to the allergy shots. There is currently no blanket coverage decision made by CMS about allergy shots, which are a type of immunotherapy. Without this national coverage determination, local Medicare contractors and doctors can make their own calls on coverage. The reasoning for this local decision-making is because allergies, their risks, and the allergen immunotherapy are highly localized and personal to each individual. In some cases, you may have an allergy, but it may not rise to the level where an allergy shot is necessary. For this reason, a doctor will likely need to say the allergy shot is medically necessary to receive coverage. It’s also worth noting that the alternative method of receiving allergen immunotherapy treatment, sublingual immunotherapy (a pill take under the tongue), is not covered by Medicare.
Without coverage, the shot may cost around $1,000 each year, so it’s good to have 80 percent of that handled by your plan.
If you do receive Medicare coverage, it’ll likely be under Medicare Part B, since the shot is given in the doctor’s office. This means you’ll owe 20 percent of the Medicare-approved amount. Without coverage, the shot may cost around $1,000 each year, so it’s good to have 80 percent of that handled by your plan. You may also owe a copayment for the office visit. Of course, should you have a Medicare Advantage plan, the allergy shot may be covered more easily or at a higher amount. This varies from plan to plan, similar to allergy testing.
Prescription Allergy Medications
Of course, not all treatment options will arise to the level of allergen immunotherapy. In some cases, a prescription antihistamine may be enough for stronger, though not life-threatening, cases of allergies. In these cases, Original Medicare, that is Parts A and B, won’t cover these prescriptions. If you have Original Medicare, you can receive coverage through a Medicare Part D plan, which does cover prescriptions. You can also use Medicare Part C (also called Medicare Advantage), which sometimes includes prescription drug coverage as part of the plan. Of course, this is just for prescription drugs. You may not have coverage for over-the-counter antihistamines, but these are often very affordable without coverage.
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Allergies are a pain, literally. Even if you’re not having an allergic reaction, taking the necessary steps to avoid a reaction can be stressful and interfere with your day-to-day life. It can get even worse if you don’t have coverage for the diagnosis and treatment of your allergies. Make sure that you’re getting the help for your allergies with a robust Medicare plan — whether that’s Original Medicare with a Part D plan, should you have any prescription allergy medications, or a Medicare Advantage plan that has prescription drug coverage! If you need any help finding or comparing these plans, we’d be happy to help you with the Medicareful plan finder tool, where you can compare plans directly and get in touch with a licensed insurance agent if you’re interested in expert assistance.