Medicare Coverage of Vaccinations and Immunizations
Medicare covers some vaccines and immunizations. The way Medicare covers them depends on which vaccine you need.
Your Medicare Part B will cover vaccines to prevent:
- Influenza (the flu); currently, the seasonal flu shot includes both a seasonal flu shot and an H1N1 (swine flu) vaccination.
Medicare Part B covers 100% of the cost of a flu shot once every flu season with no Part B deductible required. This is true for both Original Medicare and Medicare Advantage Plans.
Original Medicare will pay for the flu shot no matter where you get it, as long as the health care provider is enrolled in Medicare. You will pay no copay or deductible if you see a doctor or other health care provider who takes assignment. If you receive your Medicare benefits from a Medicare Advantage Plan, the plan cannot require that you get a referral for the vaccine, but it can require that you use providers in the plan’s network.
The flu season usually runs from November through April. Therefore, Medicare may cover a flu shot twice in one calendar year.
Medicare will cover 100% of the cost of two separate, different doses of the pneumonia vaccine with no Part B deductible required if you are in Original Medicare or a Medicare Advantage Plan.
Currently, there are two types of pneumonia vaccines available. Medicare Part B will cover an initial pneumonia vaccine if you have never received the pneumonia vaccine under Medicare Part B before. Medicare will also cover a second, different type of pneumonia vaccine at least one year after the first vaccine was administered.
Medicare Advantage Plans cannot require that you get a referral for the vaccine, but can require that you use network providers. You should call your plan to find out what rules apply. If you are in Original Medicare you will have no copay or deductible if you see providers who take assignment.
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 and when you have received any pneumonia vaccines.
Speak with your doctor to learn more about the types of pneumonia vaccines and to discuss receiving these vaccines.
- Hepatitis B (if you are at medium to high risk).
Hepatitis B is the most widespread of the hepatitis viruses. If you are at medium to high risk for hepatitis B, there is no coinsurance or deductible for the hepatitis B vaccine if you have Medicare Part B and use providers who take assignment. Doctors and other health care providers who take assignment cannot charge you more than the Medicare approved amount.
Part B will cover other immunizations only if you have been exposed to a dangerous virus or disease. For example, if you step on a rusty nail, Medicare will cover a tetanus shot; if you are bitten by a dog, Medicare will cover your rabies shots.
People who are considered high or medium risk for hepatitis B are:
- Those with End-Stage Renal Disease (ESRD) also known as kidney failure
- Clients and staff at institutions for the developmentally disabled
- Those who live in the same household as an hepatitis B carrier
- People who have unprotected sex with multiple sex partners or with someone who’s infected with Hepatitis B
- Illicit drug users
- Health care professionals who have frequent contact with blood or other body fluids during routine work
All vaccines other than those for the flu, pneumonia or hepatitis B are covered under Medicare Part D.
Note: Original Medicare covers the influenza, pneumonia, and Hepatitis B vaccines with no coinsurance or deductible if you see a provider who accepts assignment. Providers who accept assignment cannot charge you more than the Medicare approved amount. Medicare Advantage Plans will cover all preventive services the same as Original Medicare. Medicare Advantage out-of-pocket costs for vaccines and immunizations will vary depending on the type of shot. Your costs will also vary depending on if you go to an in-network or out-of-network provider.
If you have a Medicare Part D prescription drug plan, you can get coverage for any commercially available vaccine that is not covered by Part B. All Part D plans must include all commercially available vaccines on their formularies, including the vaccine for shingles (herpes zoster). Your Part D plan will pay for the vaccination itself and for your doctor or other health care provider to give you the shot (administration). Before you get a vaccination, you should check coverage rules with your Part D plan and see where you should get your shot so that it will be covered for you at the lowest cost.
However, the amount you pay for your vaccination could vary based on where you get vaccinated. Before you get a vaccination, you should check coverage rules with your Part D plan and see where you should get your shot so that it will be covered for you at the lowest cost.
You will pay the least for your vaccination if you are vaccinated at:
- A pharmacy that is in your drug plan’s network (an in-network pharmacy) if this is permitted in your state; or
- A doctor’s office that; can work with a pharmacy that will bill your Part D plan for the entire cost of the vaccination process (the drug and its injection); or will bill your plan for the vaccination process directly
In the above circumstances, you will end up paying the least for your vaccination and should only need to pay the plan’s approved coinsurance or copay for the drug and vaccination either to the doctor or to the pharmacist when you get vaccinated.
When you are at your doctor’s office, ask your doctor to call your Part D plan first to find out if there is a way that she can bill your plan for the vaccination. There may be a way for her to submit the bill so that you will not have to pay the whole cost up front.
You may need to pay more for your vaccination if your doctor
- Cannot submit the bill to your Part D plan through a partnering pharmacy; and/or
- Does not directly bill your plan for the drug using the electronic billing system.
In these circumstances, the doctor will bill you for the entire cost of the vaccination (the drug and its injection) and you will have to pay the entire bill up front. You will then have to follow your Part D plan’s rules to get a refund (reimbursement). The doctor is not limited in how much she can charge you for the vaccine but your Part D plan will only pay its approved amount for the vaccine costs. When you are reimbursed by the plan, you will only be reimbursed for your Part D plan’s approved payment. You will be responsible for the difference between the doctor’s charge and the plan’s approved payment.
If you have Extra Help, you can go to any doctor or in-network pharmacy. You will be covered for your vaccination and will only be responsible for the Extra Help copay. However, you may need to pay the entire bill up front and then be reimbursed by your Part D plan if you get vaccinated by a provider who does not directly bill your Part D plan.