Vaccines Covered Under Medicare

By Robert Lear posted 09-23-2020 08:41 PM


Vaccines can help to prevent illness from infectious diseases, which is why Medicare covers the cost of some important ones. Medicare Part B covers flu, hepatitis B and pneumonia vaccines as part of its preventative care cover. 

People do not have to pay for the vaccines covered under Medicare Part B as long as the provider accepts Medicare. Medicare Part D covers vaccines that are not covered by Part B. 

Medicare Part D coverage

Medicare Part D is prescription drug coverage for Medicare beneficiaries. It is available through a stand-alone Medicare prescription drug plan or a Medicare Advantage Plan that includes drug coverage. Part D plans have to cover most commercially available vaccines but exclude flu, hepatitis B and pneumonia vaccines, which are covered by Part B. 

Medicare Advantage plans

All Medicare Advantage plans not only include the vaccines covered by Medicare Part B but most of them cover extra vaccines included under Medicare drug plans (part D). As Medicare Advantage and Medicare Part D plans vary, vaccine coverage may vary too. 

People with these plans should contact the providers to learn more about vaccine coverage. Find out more about Medicare Advantage plans 2021 from 

Reasonable and necessary commercial vaccines

A vaccine covered by Medicare Part D could save a life as vaccine-preventable diseases can cause illness, hospitalization, and even death. Medicare Part D covers commercially available vaccines that are reasonable and necessary to prevent illness. Medicare drug plans list the vaccines they cover in their formularies. 

Shingles, Tdap and MMR

Medicare Part D covers a one-time shingles vaccine given in two shots over two to six months and all administration costs. It also covers tetanus, diphtheria and pertussis/whooping cough (Tdap) vaccine and the measles, mumps and rubella (MMR) vaccine. The Tdap consists of one shot for those who have never been vaccinated and a booster shot every ten years. 

Part D may cover shots that are necessary when traveling internationally. To see if travel vaccines are covered, it is necessary to check the plan’s formulary, or list of covered drugs 

Cost of vaccines under Part D 

The fact that Medicare Part D covers a certain vaccine does not necessarily mean that it will cost the patient nothing. The cost will depend on the type of vaccine, where it is administered and who administers it. A vaccination done in a doctor’s office, for instance, may cost more than one done at a pharmacy or clinic. 

It is always a good idea to know how much Medicare will pay for vaccines as well as what plan rules need to be followed, such as getting the vaccine at a Medicare-approved facility. 

It is possible for the doctor’s fee for administering the vaccine to exceed the plan’s allowable charge, in which case the patient has to pay the difference. 

Upfront payment or not

If patients are vaccinated in a doctor’s office, they need to check whether the office will bill the drug plan directly or not. A doctor’s office may coordinate with a pharmacy to bill the Part D plan for the whole cost of the vaccination process, including the drug and its injection. 

The patient may have to pay the costs upfront and then file a claim for reimbursement from a plan. If this is the case, it is important to contact the plan before getting the vaccine to confirm coverage. A plan will only reimburse up to an approved amount and a patient will not be refunded for any amount paid to a provider above the Part D approved amount. 

1 view