When it comes to Medicare, not all vaccines are the same.
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While we await the arrival of the COVID-19 vaccine, it’s a good time to learn about Medicare’s coverage of vaccinations. For example:
Sally lives in a small, rural community and sees the one doctor in town. She got her pneumonia vaccination during her first visit after she turned 65. Then, during her next visit in October, the doctor administered her flu shot. This all went so smoothly that she decided to schedule an appointment for the shingles shot. However, she got a big surprise. The doctor’s nurse said Sally would have to pay for the vaccination up front, about $200. She was shocked. What’s the deal, she wondered? These are all just vaccines.
They may all be vaccines but, when it comes to Medicare, they are different.
Part B vaccines
Part B, medical insurance, covers most vaccines that Medicare beneficiaries need. The Centers for Medicare and Medicaid Services (CMS) has identified these as Part B vaccines.
• Influenza virus vaccine: Medicare covers this vaccination once a year for all beneficiaries.
• Pneumococcal pneumonia: There are two vaccines—Prevnar 13® and Pneumovax® 23. Once enrolled, Medicare will cover the first vaccination at any time and the second one if it’s administered at least one year later.
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• Hepatitis B: Part B covers this vaccine for those at medium or high risk for the disease. This includes those with hemophilia, end-stage renal disease (ESRD) or diabetes, and healthcare workers who have frequent contact with blood and bodily fluids. Hepatitis B vaccine involves a series of three shots over a six-month period.
• Other vaccines directly related to treatment of an injury or direct exposure to a disease or condition: Examples include the anti-rabies treatment, tetanus booster vaccine, botulin antitoxin and immune globulin.
If you have Original Medicare, you can get the vaccine from any doctor or pharmacy that accepts Medicare assignment. If you elected Medicare Advantage, you will likely have to visit a doctor or pharmacy in the plan’s network. No matter the type of Medicare you have, you won’t pay a deducible, copayment or coinsurance.
Part D vaccines
Just about every other vaccine is likely covered under a Part D drug plan. These vaccinations include shingles, known as Shingrix, Hepatitis B administered to non-high-risk individuals, and Tdap (tetanus, diphtheria, pertussis) vaccination.
The best way to get these vaccines is to visit a pharmacy. If you have Original Medicare, check that the pharmacy is enrolled in Medicare and can submit the claim. For those with Medicare Advantage, the pharmacy should be in-network.
Because these vaccines are covered under Part D, the applicable cost sharing will apply, including the plan’s deductible and copayment or coinsurance.
What Sally learned
Her pneumonia and flu vaccines were covered when administered by her doctor because they are Part B vaccines. However, the shingles shot is a Part D drug.
Because a doctor’s office is not a pharmacy, it is not in a drug plan’s network and has not negotiated any prices. In order for Part D to cover the medication, a doctor’s office must either be able to:
- Coordinate with an in-network pharmacy to bill the vaccine, or
- Bill the plan electronically for the vaccine.
Sally’s small physician’s office could do neither. If the doctor administered her shot, she would have to pay the full cost up front for the vaccine plus the fees associated with administration. Then, Sally could submit a paper claim to the drug plan for reimbursement of the plan’s share. (She would be responsible for the plan’s cost sharing.) It’s possible that the physician’s cost for the vaccination might be more than the plan’s approved amount, which would be money out of Sally’s pocket.
Sally quickly learned that her best option will be to go to an in-network pharmacy. She thinks this will be less convenient for her, but it will certainly be more cost-effective.