Vaccines covered by Medicare
Medicare prescription drug plans cover wide variety of prescription drugs, this includes several vaccines covered by Medicare. Medicare covers vaccines in more than one way; either by Part D or by Part B (medical coverage) or Part C MA/MAPD plans that may provide coverage for all the parts of Medicare. It all depends on the type of vaccination and what facility the patient receives it at. As of January 2023, all vaccines covered by Medicare should be free to beneficiaries. This means they should not have any cost-sharing such as; co-pays, co-insurance or deductibles.
In many cases, if the vaccination is part of a treatment for an illness or injury, it is usually covered by Part B. In other words, if a beneficiary gets a puncture wound, they may need a tetanus shot. When this is the case, the vaccination falls under Medicare Part B coverage (Part C, if they have an MA/MAPD plan). If the beneficiary opts to receive a tetanus booster shot, that charge falls under their Part D plan.
Here are some common vaccines that Part B covers:
*Hepatitis B – in cases where the individual is at high to intermediate risk.
*Some necessary vaccines needed to treat an injury, illness or exposure to a disease.
Part B covers some drugs
In some instances, Part B covers drugs beneficiaries do not normally give themselves. In other words drugs that you receive either in a doctor’s office or in an outpatient hospital setting.
A few of the drugs covered by Part B
- Flu shots (including seasonal and H1N1 Swine flu)
- Pneumonia (pneumococcal) vaccines.
- Leqembi (generic name – lecanemab) – This is a new medication used to treat symptoms of Alzheimer’s.
- Injectable osteoporosis drugs, such as Prolia or Xgeva, if the beneficiary meets the criteria.
- Antigens that the doctor prepares and provides instruction to administer. The patient may self- administer the drugs with proper instruction and supervision.
- Drugs the beneficiary uses with DME (durable medical equipment) such as; infusion pumps or nebulizers.
Part D vaccine coverage
Part D Vaccines are provided in an effort to prevent illness as opposed to treating one. Medicare Part D plans cover commercial vaccines if they are reasonably necessary.
Some vaccines covered by Part D
- Shingles vaccines
- Tdap (tetanus-diphtheria-whooping cough) vaccines
- In cases that a PDP plan’s formulary does not list a vaccine, it must provide coverage if a physician prescribes it as a prevention measure.
As of January 2023, patients with Medicare Part D plans or MAPD plans pay no out-of-pocket costs for adult vaccines. This is part of the Inflation Reduction Act of 2022. If the patient is charged a vaccine administration fee at the time of service, they can submit this amount to their Part D plan for full reimbursement.