How does Medicare cover vaccines?
June 1, 2018
Many of you may have heard that there is a new vaccine available for the shingles virus that is proving to be more effective than the previous vaccine, Zostavax. The new vaccine is recommended for people age 50 and older. Called Shingrix, the vaccination does require two doses, the second to be administered between two to six months after the first.
Medicare requires all Part D (prescription drug coverage) plans to cover both shingles vaccines. Shingles, also known as herpes zoster, appears as a rash that typically attacks one side of the body or face. It is caused by the same virus that causes the chickenpox. Victims may experience pain, tingling, or itching as well as the rash and blisters. The symptoms typically last between one to two months. Shingles can lead to several other severe conditions like pneumonia, issues with hearing and vision, even brain inflammation or death. A few patients, about one fifth, may experience long term post-herpetic neuralgia. The new shingles vaccine is recommended even if you have received the Zostavax vaccine.
Other vaccines that Medicare requires Part D plans to cover include diphtheria and tetanus (Tdap), pertussis (whooping cough) and pneumonia (pneumococcal).
In-network and other coverage concerns
You may want to be aware of the following tips when getting a Part D-covered vaccine.
If you are getting your vaccine in a doctor’s office, be certain that your doctor has the ability to bill your Part D plan or can work with a pharmacy in your Part D plan’s network. Otherwise, you may have to pay the whole bill upfront and then request reimbursement from your plan.
If you are getting your vaccination in a pharmacy, make sure it is an in-network pharmacy for your plan. That way they can bill your plan directly. If the pharmacy has a preferred pharmacy status with your plan, you will pay the lowest co-pay.
It is important to know what part of Medicare covers the vaccine that you are getting because some people have prescription drug coverage from retiree insurance. If you have prescription coverage from a source other than Medicare, check with that insurance company to determine if they cover vaccinations under their plan. If they do not, and it is only covered under Part D of Medicare, you may have to pay for it yourself.
Flu, hepatitis B shots
There are certain vaccinations that are always covered by Part B. For example the seasonal flu shot. Medicare does cover one flu vaccine per flu season. If there is more than one flu season per year, you may get a vaccination each flu season. You will have no co-pay if you have Part B and the provider administering the vaccine takes assignment, which means they have an agreement with Medicare to accept the payment amount that Medicare says is reasonable. The swine flu (H1N1) is also covered under the flu shot benefit.
Hepatitis B shots are covered by Part B for those who have medium to high risk for hepatitis B. Your risk is higher for hepatitis B if you have hemophilia, End Stage Renal Disease (ESRD), diabetes, or if you work in the health care field and have contact with bodily fluids. Again, you pay nothing for the shot if your provider accepts assignment.
Part B will cover two separate pneumonia vaccines. The first shot is covered if you have never received Part B coverage for this vaccine before. You are also covered one year later for a second shot. A written vaccination history is not required when receiving the pneumonia vaccine. You are allowed to give a verbal history of if or when you received past vaccinations. As with the other Part B covered vaccines, Medicare will pay 100 percent as long as you are receiving the vaccination from a provider that takes assignment, also referred to as a participating provider. This means you do not have to meet any deductibles or pay a co-insurance.
Keep it simple to keep current
You may want to discuss your vaccination status with your provider when you first get Part B at your Welcome to Medicare Preventive Visit. This visit is available during the first 12 months that you have Part B and is a great way to set up a schedule of the preventive screenings, tests and vaccinations that Medicare covers at 100 percent. After that, you will have opportunity to discuss your vaccination status at the Annual Wellness Visit which can be scheduled 12 months after the Welcome to Medicare Preventive Visit or 12 months after your Part B becomes effective. This yearly visit will help you to stay abreast of what vaccinations may be due.
Nila Morgan is a Certified Medicare Specialist who works at the Anchorage Senior Activity Center.