Lately, we’ve been getting a lot of questions about vaccines and how they’re covered by Medicare.
All commercially available vaccines are generally covered by Medicare; however, vaccines can be covered by Medicare Part B or your Medicare Part D Prescription Drug Plan depending on the vaccine or circumstance.
Covered by Medicare Part B [Doctor office or approved Medicare supplier will administer]:
Influenza virus vaccine (Flu): Medicare Part B will always pay 100% of the cost for one flu shot per flu season if your provider accepts your Medicare plan.
Pneumococcal (pneumonia) vaccines: Medicare Part B covers 100% of the cost for both pneumococcal vaccines when administered at least 12 months apart.
Covered by Medicare Part D [Pharmacy will administer]:
Hepatitis B vaccine for patients at high or intermediate risk: Medicare Part B covers 100% of the cost for this series of shots if your provider accepts your Medicare plan and you are considered at high or intermediate risk. If you are not considered at risk, Part D generally covers this vaccination. You are at risk if you have End-Stage Renal Disease (ESRD), hemophilia, or diabetes. You are also at risk if you live with someone who has Hepatitis B. Or if work in an environment with frequent contact with blood and/or bodily fluids.
Tetanus, diphtheria, pertussis vaccine (Tdap): A booster shot is recommended every 10 years, and will be generally covered by Part D. This vaccination is only covered by Part B if it is a direct treatment of an injury.
Shingles vaccine: The CDC recommends the Recombinant Zoster Vaccine (RZV) known by the brand name of Shingrix to prevent Shingles, even for those who received the initial vaccine for Shingles known as Zostavax. Contact your doctor to determine if you should receive this vaccination.
Vaccines directly related to the treatment of an injury or direct exposure to a disease or condition. Examples include but are not limited to: Receiving a Tetanus shot (Tdap) after puncturing yourself. Receiving a Rabies shot after being bitten or scratched by an infected animal.
It’s important to note, your Part D (Prescription Drug Plan) generally covers all other commercially available vaccines. Please contact your Part D plan for specific information about coverage of a vaccine as each formulary is different. The following are vaccinations that are commonly needed by our clients and are generally covered by Part D. Remember: just because your prescription drug plan “covers” a vaccine, does not mean that a copayment will not be required.
Additionally, you should talk to your Part D plan to discuss the cost-share and allowable charges for the vaccine. You should make sure that the pharmacy you’re going to is a preferred pharmacy, to ensure best pricing. The cost-sharing is different for each person. If your plan has a deductible that you have not met for the year, it could be costly.
