Vaccine Coverage Through Medicare Part D
Generally, Medicare prescription drug coverage covers all commercially available vaccines needed to prevent illness. To be safe, you should always check with your plans Member Services team first if youre thinking about getting a specific vaccine.
You can get Part D coverage through a stand-alone prescription drug plan, or through a Medicare health plan like Medicare Advantage. If you dont have prescription drug coverage, you might have to pay full price for the other vaccines you need or want.
Why Doesn’t Medicare Cover The Shingles Vaccine As Free For All Seniors
Many people think that a vaccine that’s recommended by the CDC for those over age 50 would be fully covered by Original Medicare. However, there are a few reasons why you may end up paying hundreds of dollars for the two-dose regimen.
- Medicare coverage levels: Some Medicare drug plans have better cost-sharing benefits than others, and how much you pay for the shingles vaccine depends on the plan you choose.
- Pharmaceutical classification: Medicare classifies the Shingrix vaccine as a part of its pharmaceutical coverage, meaning it would fall under Medicare Part D coverage rather than Part A or Part B. In contrast, most private health insurance, either through an employer or through the marketplace, classifies the shingles vaccine as a part of its free preventative coverage.
- Type of pharmaceutical: Shingrix is a Tier 3 drug made by GlaxoSmithKline, and there isn’t a generic alternative. This could mean that your out-of-pocket costs are higher than for other medications.
Does Medicare Cover Other Vaccines
Flu shots arent the only vaccines covered by Medicare.
Medicare Part B and Medicare Advantage plans also cover preventive vaccines such as pneumonia shots and Hepatitis B shots. Medicare Part B and Medicare Advantage plans may also cover vaccines such as rabies shots if they are considered medically necessary by a doctor.
Specific costs, including monthly premiums, deductibles and coinsurance will vary depending on the Medicare Advantage plan you enroll in.
A licensed insurance agent can help you compare Medicare Advantage plans in your area and get you enrolled in a plan that works for you.
Find Medicare Advantage plans in your area
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About the author
Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles hes written, helping Americans better understand their health insurance and Medicare coverage.
Christians work as a Medicare expert has appeared in several top-tier and trade news outlets including Forbes, MarketWatch, WebMD and Yahoo! Finance.
Christians passion for his role stems from his desire to make a difference in the senior community. He strongly believes that the more beneficiaries know about their Medicare coverage, the better their overall health and wellness is as a result.
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Medicare Advantage Plans May Cover More Vaccines Than Original Medicare
Medicare Advantage plans are sold by private insurance companies as an alternative to Original Medicare.
Every Medicare Advantage plan must provide the same hospital and medical benefits as Medicare Part A and Part B, and most plans include Medicare prescription drug coverage.
MAPDs must help cover a number of commercially available vaccines that arent covered by Original Medicare when reasonably and medically necessary to prevent illness. However, specific rules of administration and costs will vary depending on the Medicare Advantage plan you enroll in.
A licensed insurance agent can help you compare Medicare Advantage plans in your area, including what vaccinations may be covered.
Find Medicare plans that cover your vaccinations
Or call 1-800-557-6059TTY Users: 711 to speak with a licensed insurance agent. We accept calls 24/7!
About the author
Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles hes written, helping Americans better understand their health insurance and Medicare coverage.
Christians work as a Medicare expert has appeared in several top-tier and trade news outlets including Forbes, MarketWatch, WebMD and Yahoo! Finance.
A current resident of Raleigh, Christian is a graduate of Shippensburg University with a bachelors degree in journalism.
What Is The Pneumococcal Vaccine And How Often Should You Get It
Both pneumococcal vaccines approved for use in the United States protect against multiple types of bacteria that can cause pneumonia. The schedule for taking them depends on your age and medical conditions.
Differences Between Pneumococcal Vaccinations
- Pneumovax 23
- Pneumovax 23 protects against 23 types of serious pneumococcal bacterial infections. Most adults will need only one shot of PPSV23 in their lifetime. But the CDC recommends up to two additional shots for adults with certain chronic medical conditions.
- Prevnar 13
- Prevnar 13 protects against the 13 most common types of pneumococcal bacteria that cause the most common serious infections in children and adults. Adults will receive this shot only if they have certain medical conditions and with the advice of their doctor. While children receive seven doses by the time they are 15 months old, adults who get this vaccine will only receive one shot of PCV13 in their lifetime.
- Prevnar 20
- Prevnar 20 is similar to Prevnar 13, but provides protection against 20 different types of pneumococcal bacteria. It is a more recent addition and Medicare began covering it in October 2021.
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How Much Does Prevnar 13 Cost
As long as your provider is enrolled in Medicare, Part B will cover the complete cost of Prevnar 13, with no copay or coinsurance required. The Part B deductible doesnt apply to the pneumonia shot, so you shouldnt receive a bill or be asked to pay any portion of its cost up front.
If you have Part C, make sure to use an in-network provider. A list of these providers should be available on your plans website. If you dont use an in-network provider, you may get stuck with out-of-pocket costs for Prevnar 13.
vaccine. It protects against pneumococcal disease caused by Streptococcus pneumonia. This is a type of a bacteria that has more than 90 different strains.
Prevnar 13 protects against 13 Streptococcus strains.
In 2019, the CDCs Advisory Committee on Immunization Practices changed its recommendations for immunization with Prevnar 13 in people over age 65.
This change wasnt based on any problem with the vaccine, but rather on the success of its use in children. Because so many children are now routinely vaccinated with Prevnar 13, the prevalence of the bacterial strains it protects against has sharply declined in the United States.
However, Prevnar 13 is still recommended for certain people ages 65 and over, such as those who:
- live with a cerebrospinal fluid leak
- live in long-term care facilities, such as nursing homes
- travel to areas where children are not routinely given Prevnar 13
You and your doctor may instead decide that you need only Pneumovax 23.
How Much Does The Vaccine Cost
The pneumococcal vaccine will usually cost somewhere between $90 and $150 if you pay out-of-pocket. This entire cost will be covered by Medicare Part B health insurance for the first two doses that you receive. After this, you may have to pay the entire cost out of pocket, or just pay a portion depending on the specific details of your situation.
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What Pneumonia Vaccine Is Recommended For Seniors
The current guidance by CDC recommends adults 65 years and older get the PPSV23 vaccine to protect against pneumococcal pneumonia and other types of severe pneumococcal disease.
You may need both the PPSV23 and the PCV13 shots if youre at higher risk . You and your doctor will decide if you need the additional pneumococcal vaccine .
Symptoms of pneumonia include cough, chills, fever, trouble breathing and chest pain. In serious cases, pneumonia can be life-threatening and require hospitalization.
Pneumonia infections may be caused by multiple organisms . You are at increased risk of developing pneumonia after a respiratory viral illness like influenza or other respiratory infections. So its a good idea to get the flu shot each year.
Individuals 65 years and older, children younger than two years, people who smoke, and those with other health conditions like asthma, diabetes, chronic obstructive pulmonary disease (COPD, liver, heart, or kidney disease, and immunocompromised people are at greater risk for serious pneumococcal infection.
Does Medicare Cover Shingles Vaccine
Original Medicare doesnt cover shingles vaccines, but that doesnt necessarily mean youll have to pay for it out-of-pocket. The shingles vaccine is required to be one of the vaccines covered by Medicare Part D Prescription Drug plans.
In fact, most vaccines are covered under your prescriptionplan, rather than by Original Medicare. You should check with your specificplan for information such as what your costs will be, which vaccines you canreceive, and where you can go to receive them. Like Original Medicare, some vaccinescovered by Medicare Part D Prescription Drug plans may have eligibilityrestrictions, so be sure to ask your healthcare provider if you qualify.
Being properly vaccinated helps prevent you from catchingavoidable illnesses, and from spreading them to the people around you. Medicarevaccine coverage makes it easy and affordable to stay up to date with yourshots, so you have one less thing to worry about when it comes to your health. Ifyou have questions about eligibility, costs, or whether you should get avaccine, you should consult with your healthcare provider.
Nothing on this website should ever be used as a substitutefor professional medical advice. You should always consult with your medicalprovider regarding diagnosis or treatment for a health condition, includingdecisions about the correct medication for your condition, as well as prior toundertaking any specific exercise or dietary routine.
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Do I Have To Pay For Vaccines With Medicare
You pay nothing for vaccines covered by Part B flu, pneumonia and Hepatitis B as long as your provider accepts Medicare.
Your cost for vaccines covered by Part D will depend on your specific plan. You may pay a copay or coinsurance, but it will depend on your plan and the provider.
The location where you get vaccinated may also affect your cost. For example, your costs may be lower if you get a vaccine at a pharmacy versus in a doctors office.
Medicare Vaccine Coverage Through Part B
If you have Original Medicare Parts A and B, or a Medicare plan from a private insurance company, your medical coverage usually takes care of the most common immunizations. Private Medicare health plans also cover additional vaccines through their Part D benefit, which well talk about later in this article.
In some cases, your medical coverage will cover certain vaccines if youre at risk of getting a related disease or illness. If you have Original Medicare, its easy to check if your vaccine is covered. If you get your Medicare benefits through a private insurance company, contact them directly to see if your vaccine is covered.
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What Types Of The Vaccine Are There
Like some other vaccines out there, there is more than one type of pneumococcal vaccine. The main varieties are known as PCV13 and PPSV23. PCV13 stands for pneumococcal conjugate vaccine, while PPSV23 is stands for pneumococcal polysaccharide vaccine. The numbers reflect the number of bacterial strains that the vaccine protects against: 13 and 23 respectively
Usually, it is suggested that children under 2 receive the PCV13 vaccine, while seniors receive the PPSV23 vaccine. However, your doctor will let you know which vaccine you need to take, as some people with certain conditions have different needs. Medical advice should be received only from your doctor.
How To Get Part D Coverage
You can get Medicare Part D coverage either through a stand-alone Part D Medicare Prescription Drug Plan or through a Medicare Advantage plan that includes prescription drug coverage. Both stand-alone Medicare Part D Prescription Drug Plans and Medicare Advantage plans are available from private, Medicare-approved insurance companies. With a stand-alone Medicare Part D Prescription Drug Plan, you will keep your Original Medicare coverage. A Medicare Advantage plan is another way to get you Part A and Part B benefits although you must continue to pay your Part B premium as well as any premium the plan may charge. Hospice benefits are still covered directly under Medicare Part A.
Would you like to know more about Medicare coverage of vaccines? Iâd be happy to help you. I can walk you through your options or email you information you can request that using the links below. Or take a look at plans by clicking the Compare Plans buttons on this page.
Medicare information is everywhere. What is hard is knowing which information to trust. Because eHealthâs Medicare related content is compliant with CMS regulations, you can rest assured youâre getting accurate information so you can make the right decisions for your coverage.Read more to learn about our Compliance Program.
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When To Get Your Shots
The best time to get your flu and pneumonia shots is any time after July 1 each year. This is because flu season typically begins in the fall. Peak months for the flu season in Michigan are November, December, January, February, March and April.
The flu spreads quickly during those peak months. So, getting vaccinated early is important, because it gives your body a chance to protect itself.
Is The Shingles Shot Covered By Medicare
Original Medicare does not pay for the shingles vaccine. However, if youre enrolled in a Medicare prescription drug plan or have a Medicare Advantage plan that includes drug coverage, your shot may be covered. For vaccines covered under Part D , it is not recommended to get the shot through your providers office, as you may have issues with Part D billing.*
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Indications For Tdap Vaccination
In addition to the standalone tetanus shot, it is also recommended that you get at least one Tdap booster as an adult, which protects against tetanus, diphtheria, and pertussis . It is also recommended during the third trimester of pregnancy.
However, the Tdap vaccine is currently not covered under the Part B benefit and may or may not be covered by your Medicare Advantage plan or Part D plan. Check your plan’s formulary.
What Vaccines Do Medicare Part D Cover
Medicare Part D is optional prescription drug coverage through a private insurance company. You can get prescription drug coverage through a stand-alone Prescription Drug Plan or a Medicare Advantage plan with prescription drug coverage. Generally Part D covers all commercially available vaccines needed to prevent illness.
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How Often Can I Get The Vaccine
Medicare will pay for your vaccination under your Part B coverage. You will be able to get two vaccinations: one at any time you choose, and another fully covered vaccination at least one year after the first.
If your doctor notes that you need another pneumococcal vaccination, you may need to pay some or all of the cost associated. If this is the case, make sure you understand how much you will have to pay beforehand, if possible.
You will only receive full coverage for your pneumococcal vaccination if your doctor accepts Medicare assignment. This means that they charge only the Medicare-approved amount for their services, which results in no excess charges. If youre unsure whether or not your doctor accepts Medicare assignment, they should be able to tell you.
Where To Get Your Shots
You can get your flu and pneumonia shots at the following locations:
- Your doctors office. Call your primary care physician and make an appointment. Your office visit copay may apply for the visit, but the shots will come at no cost.
- A pharmacy. Call your local pharmacy before you go to make sure they offer flu and pneumonia shots. Youll also want to make sure that the pharmacy accepts your Medicare plan. Our pharmacy directory can help you find a location, too.
- A community health center. You can check with your local health department to see if there are community health centers that offer these shots and accept your Medicare plan.
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What Parts Of Medicare Cover The Vaccine
Many vaccines are covered by Medicare Part D, which offers prescription drug coverage. However, Part D prescription drug coverage usually wont cover something thats already covered by Part B medical insurance. Pneumonia shots are covered by Part B, but remember that many other vaccinations are covered by Part D instead.
About The Shingles Vaccine
The Centers for Disease Control and Prevention recommends that healthy adults over the age of 50 get the shingles vaccine because it’s the only way to protect against the disease and its associated side effects. The risk of getting shingles increases as you age or if you have a weakened immune system. Always consult your doctor to find out if the shingles vaccine is right for you.
The CDC-recommended vaccine, Shingrix, is a recombinant zoster vaccine that has two doses administered within six months of each other. It’s classified as a Tier 3 drug by most insurance companies, which means it’s a brand-name pharmaceutical with a higher copayment than a Tier 1 or 2 drug.
Use the Shingrix vaccine locator to find where the shingles vaccine is being offered, and check with your Medicare Part D or Medicare Advantage provider to see which locations give you the lowest price.
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Who Should Get Pneumococcal Vaccines
CDC recommends pneumococcal vaccination for all children younger than 2 years old and all adults 65 years or older. In certain situations, older children and other adults should also get pneumococcal vaccines. Below is more information about who should and should not get each type of pneumococcal vaccine.
Talk to your or your childs doctor about what is best for your specific situation.
