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A Guide to Medicare and Vaccines

Coronavirus disease is making headlines, so many of us have immunity on the mind. Not to mention: Cases of the flu hit many parts of the United States every year.

Though the coronavirus and the flu are two completely different threats, the likeliness of contracting either illness is higher for older Americans:

  • Coronavirus: At least 50% of the U.S. coronavirus cases were in people who are 50 and older (as of Feb. 7, 2020).
  • Flu: Over 60% of seasonal flu-related hospitalizations occur in people who are 65 and older.

There’s currently no vaccine for coronavirus, but there is a flu vaccine that can help immunize you against the flu. And the good news is: The flu vaccine is covered by Medicare, along with other vaccinations you may need.

Of course, you’ll want to talk with your doctor about which vaccines are appropriate for you and your health. Once you know what you need, you might ask: “Will Medicare cover my vaccine?”

Let’s take a look at how Medicare Part B and Medicare Part D cover some common vaccines.

Medicare Part B

Medicare Part B is medical insurance that covers doctor visits, outpatient care, home healthcare, durable medical equipment, and many preventive care services. Monthly premiums vary based on your income, and there is a deductible of $198 in 2020.

Medicare Part B coverage is included in Original Medicare and Medicare Advantage.

What Vaccines Does Medicare Part B Cover?

  • Flu shots: Part B covers one flu shot per flu season.
  • Hepatitis B shots: Part B coverage depends. You pay nothing for Hepatitis B vaccines if you’re at medium or high risk for Hepatitis B. You may also pay nothing if your doctor or other qualified healthcare provider accepts assignment. Always consult with your doctor first.
  • Pneumococcal shots: This is a series of two shots: Part B covers the first shot. Part B will cover the second shot if you receive it at least one year after the first. You may also pay nothing if your doctor or other qualified healthcare provider accepts assignment.
  • Shingles shots: Not covered by Part B.
  • Tdap shots: Not covered by Part B, but your Medicare Part D plan may cover them.

Part B may also cover vaccines directly related to treatment of an injury or direct exposure to a disease.

Still, your vaccines may not be covered if you don’t use the right provider. If you have Original Medicare, make sure your healthcare provider accepts Medicare. If you have Medicare Advantage, see a healthcare provider within your plan’s network.

Medicare Part D + How It Works

Medicare Part D is prescription drug coverage that supplements Part B. Medicare Part D covers a limited number of prescription medications and vaccines.

Part D can help with the cost of prescription drugs and many recommended vaccines.

Medicare Part D is offered only through private insurers, but all Part D plans must offer a standard level of coverage set by Medicare. Your Part D plan's formulary will determine what prescription drugs and vaccines are covered.

What Vaccines Does Medicare Part D Cover?

Part D plans cover all commercially available vaccines when reasonable and necessary to prevent illness, with exception to those vaccines that are already covered by Medicare Part B. Covered vaccines may include:

  • Hepatitis B shots: Part D may cover Hepatitis B vaccines if you are not considered intermediate or high risk for Hepatitis B, in which case this vaccine is covered by Part B.
  • Shingles shots: Part D generally covers the shingles (herpes zoster) vaccine.
  • Tdap shots: Part D plans typically cover Tdap shots, which is the booster for tetanus, diphtheria and pertussis (also known as whooping cough).

Your out-of-pocket costs will depend on your Part D plan formulary and where you get the vaccine (doctor’s office vs. a walk-in clinic). Other factors that impact costs include whether or not you’ve met your plan deductible, your plan’s coinsurance (if you have one), and your plan’s copayment amounts.

In 2020, no Medicare drug plan can have a deductible that exceeds $435.

Example Vaccine Costs with Medicare Part D

Let’s look at two examples of what your cost for a vaccine could be with Part D (based on Healthcare Bluebook's price breakdown):

  • A Hepatitis B vaccine in Miami could cost around $67 at a walk-in clinic and $145 at a doctor’s office. Part D plans in Miami (33101) cover this vaccine as a tier 3 (preferred brand drug) and the beneficiary would pay a copay ranging from $26 to $47.
  • A Tdap vaccine in Miami may cost $67 at a walk-in clinic and $36 at a physician’s office. Part D plans in Miami (33101) cover this vaccine as a tier 3 (preferred brand drug) and the beneficiary would again pay a copay ranging from $26 to $47.

Your Part D plan may have prior authorization and could require a copayment for certain vaccines. In some cases, you may be required to pay for the vaccine upfront, up to your plan’s allowable charge. You would then submit a claim to your Part D plan for reimbursement.

Check your plan policy to see what's covered under Part D before you get a vaccine.

Which Medicare Plan is Right for You?

It can be difficult to navigate Medicare, the various plans, and what they cover. But we’re here to help make Medicare easy.

Whatever Medicare questions you have, we can help you find, compare and enroll in Medicare plans. Get a complimentary consultation today.

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