Dear Marci,
I have Medicare, and my doctor has recommended getting several vaccines in the coming year. How will Medicare cover these vaccines?
-Lorelai (Lancaster, PA)
Dear Lorelai,
Vaccines that you receive in an outpatient setting may be covered by Medicare Part B or Part D. Part D covers most vaccines that your doctor recommends you get, with a few exceptions (see below). Part D plans must include most commercially available vaccines on their formularies, including the vaccine for shingles (herpes zoster).
The amount you pay for your vaccine may vary depending on where you are vaccinated. Make sure to check your plan’s coverage rules and see where you can get your vaccine at the lowest cost. Typically, you will pay the least for your vaccinations at:
- In-network pharmacies
- A doctor’s office that
- Coordinates with a pharmacy to bill your Part D plan for the entire cost of the vaccination process (the drug and its injection)
- Or, can bill your plan directly for the vaccination process using an electronic billing system
When you are vaccinated in either of the above settings, you should only need to pay the plan’s approved coinsurance or copay for the drug and vaccination process. When you get a vaccine, ask the provider to call your Part D plan first to find out if your provider can bill your Part D plan directly. If this is possible, you should not have to pay the full out-of-pocket cost and later request reimbursement from your plan.
You may end up paying more for your vaccination if your provider:
- Cannot coordinate with a pharmacy to bill your Part D plan for the entire cost of the vaccination process (the drug and its injection)
- And/or, cannot bill your plan directly for the vaccination process using an electronic billing system
In these circumstances, your provider will bill you for the entire cost of the vaccination (the drug and its injection). You will have to pay the entire bill up front and request reimbursement from your Part D plan. It is important to know that your provider may charge you more than the Part D-approved amount for the vaccination, but your plan will only reimburse up to the approved amount—and you will not be refunded for any amount you pay the provider above the Part D-approved amount.
If you have Extra Help, the federal program that helps pay for some to most of the out-of-pocket costs of Medicare prescription drug coverage, you can go to any provider or in-network pharmacy to get vaccines. You will be covered for your vaccination and will only be responsible for the Extra Help copay. However, if you get your vaccine from a provider who does not directly bill your plan, you may need to pay the entire bill up front and then request reimbursement from your plan.
Part B covers the vaccines for the flu, pneumonia, and hepatitis B in the following situations:
- Flu: Part B covers one flu shot every flu season. The flu season runs from November through April. Depending on when you choose to get your flu shot, Medicare may cover a flu shot twice in one calendar year. For example, if you get a shot in January 2019 for the 2018/2019 flu season, you could get another shot in October 2019 for the 2019/2020 flu season.
- Pneumonia: Part B covers two separate pneumonia vaccines. Part B covers the first shot if you have never received Part B coverage for a pneumonia shot before. You are covered for a different, second vaccination one year after receiving the first shot. You are not required to provide a vaccination history when receiving the pneumonia vaccine. You can verbally tell the health care professional administering the shot if/when you have received past shots.
- Hepatitis B: Medicare Part B covers the hepatitis B vaccine if you are at medium or high risk for hepatitis B (If you are at a low risk, the shot will be covered under Part D).
If you qualify for Part B coverage of a flu, pneumonia, or hepatitis B shot, Original Medicare covers these vaccinations at 100% of the Medicare-approved amount when you receive the service from a participating provider. This means you pay nothing (no deductible or coinsurance). Medicare Advantage Plans are required to cover these vaccines without applying deductibles, copayments, or coinsurance when you see an in-network provider and meet Medicare’s eligibility requirements for the service.
Part B also covers certain vaccines after you have been exposed to a dangerous virus or disease. For example, Part B will cover a tetanus shot if you step on a rusty nail, or a rabies shot if you are bitten by a dog. Original Medicare covers 80% of the Medicare approved amount for these vaccines after you meet the Part B deductible, and you will be responsible for a 20% coinsurance charge. If you have a Medicare Advantage Plan, contact your plan to learn about the cost-sharing for vaccines like these.
-Marci
