November 2021: Medicare Coverage of Vaccines

Vaccines covered by Medicare Part B

Medicare Part D covers most vaccines and immunizations, but there are certain vaccinations that are covered by Part B:

  • Flu shots
    • Medicare covers one flu shot every flu season. The flu season usually runs from November through April. Depending on when you choose to get your flu shot, Medicare may cover a flu shot twice in one calendar year.
      • For example, if you got a shot in January 2021 for the 2020/2021 flu season, you could get another shot in November 2021 for the 2021/2022 flu season.
  • Pneumonia shots
    • Medicare covers a first dose if you have never received Part B coverage for a pneumonia shot before. You are covered for a different, second vaccination one year after receiving the first shot.
  • Hepatitis B shots
    • Medicare covers the hepatitis B vaccine if you are at medium or high risk for hepatitis B. If you are at low risk, the shot will be covered under Part D.
      • Medicare considers you at medium or high risk if you, for example, have End-Stage Renal Disease, have hemophilia or diabetes, use injection drugs, live with someone with hepatitis B, or are a health care professional in frequent contact with blood or body fluids during routine work. Other factors may also increase your risk for Hepatitis B. Check with your doctor to see if you’re at high or medium risk for Hepatitis B.
  • COVID-19 vaccine
    • Original Medicare Part B covers COVID-19 vaccines with no cost-sharing, whether you have Original Medicare or a Medicare Advantage Plan. You should bring your red, white, and blue Medicare card with you to your vaccination appointment, even if you have a Medicare Advantage Plan.

Vaccines covered by Medicare Part D

If your provider recommends that you get a vaccine, in most cases it will be covered by your Part D plan. Part D plans must include most commercially available vaccines on their formularies. The only exceptions are those vaccines covered by Part B.

The costs of vaccines covered by Medicare Part D

The amount you pay for your vaccine may vary depending on where you get vaccinated. Be sure to check your plan’s coverage rules and see where you can get your vaccine at the lowest cost. Typically, you will pay the least for your vaccinations at:

  • In-network pharmacies
  • A doctor’s office that
    • Coordinates with a pharmacy to bill your Part D plan for the entire cost of the vaccination process (the drug and its injection)
    • Or, can bill your plan directly for the vaccination process using an electronic billing system

When you are vaccinated in either of the above settings, you should only need to pay the plan’s approved coinsurance or copay for the drug and vaccination process. When you get a vaccine at your doctor’s office, ask the provider to call your Part D plan first to find out if your provider can bill your Part D plan directly. If this is possible, you should not have to pay the full out-of-pocket cost and later request reimbursement from your plan.

Otherwise, your provider will bill you for the entire cost of the vaccination (the drug and its injection). You will have to pay the entire bill up front and request reimbursement from your Part D plan. It is important to know that your provider may charge you more than the Part D approved amount for the vaccination, but your plan will only reimburse up to the approved amount—and you may not be refunded by the provider for any amount you pay the provider above the Part D approved amount.