How does your employer health benefit plan cover vaccines?

My sister-in-law’s milestone birthday this year brought her the Big 5-0 and a case of Shingles – affecting her eye! I knew that Shingles generally afflicts people over 50 but we were particularly concerned her occurrence could lead to more serious complications. So I did some research on the virus for my education since I am older than her and then headed to CVS for a vaccine.

Based on my recent experience. I decided to share some basics about how Medicare would cover various vaccines for beneficiaries. 

Vaccines are important for maintaining good health. The Centers for Disease Control and Prevention (CDC) recommends the following vaccines for adults 65 and older:

• Flu
• Tdap or Td (tetanus, diphtheria, pertussis)
• Shingles (zoster)
• Pneumococcal (pneumonia)
• Chickenpox (if you did not get this vaccine as a child)

So, how would some of the more common vaccines be covered by Medicare? 

According to Medicare, a vaccine can be submitted under Part B or Part D depending on several factors. Then, depending on the vaccine type and your coverage, the plan may cover only a portion, apply a deductible first, or not cover the vaccine at all.  How do you determine if the vaccine you need is covered?

Confirming coverage requires a bit of research, so it’s important when considering any vaccine to review what Medicare Part B covers and the Part D drug benefit coverage you are enrolled in before receiving your vaccine.  No one likes cost surprises.

Some general vaccine info:

Original Medicare Part B (Medical) is billed and there is little or no copay for:

• Hepatitis B vaccine (for patients at high or intermediate risk) 
• Influenza virus vaccine 
• Pneumococcal pneumonia vaccine
• Vaccines directly related to the treatment of an injury or direct exposure to a disease or condition For instance, if a beneficiary needs a tetanus vaccination due to an accidental puncture wound, it would be covered under Part B. However, simply needed a booster shot of a tetanus vaccine, unrelated to injury or illness, would be submitted under Part D for coverage consideration. 
• Reference www.medicare.gov and your drug plan for a full list of what Medicare covers.

Part D (Prescription Drug Plans) may or may not provide benefit coverage for other vaccines and with varying member responsibility:

• *Important*- Confirm your vaccine coverage details with your particular Part D insurance carrier before receiving your vaccine. 
• Part D plans will list covered drugs and vaccines through their specific drug formularies- not all plans cover all vaccines and some may apply deductible first.
• Part D plans may have special rules, such as prior authorization, step therapy, and quantity limits before coverage applies. 
• Vaccines may include an ‘administration fee’ with the vaccine cost that should be disclosed by the person administering the vaccine.
• Sometimes the beneficiary pays for the vaccine and then submits a paper claim to Part D plan for reimbursement up to the plan’s allowable charge. If the amount the physician charges is different from the plan’s allowable charge, a balance may remain that the beneficiary would not be reimbursed for. 
• Reference www.medicare.gov and your drug plan for a full list of what Medicare covers.

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– Lora