Dear Marci,

I got a pamphletfrom my doctor’s office reminding me to get all necessary vaccines. I want to talk to my doctor about getting these vaccines, but I’m not sure how Medicare will cover them. How does Medicare cover vaccines?- Eddie (Denver, CO)

Dear Eddie,

Medicare covers vaccines differently depending on which vaccine you need. Most vaccines are covered under Part D, but some are covered under Part B. Different costs apply to vaccines depending on how they are covered.

Medicare Part B covers vaccines if you have been exposed to a dangerous disease. For example, if you step on a rusty nail, Medicare will cover a tetanus shot. Additionally, Medicare Part B covers the influenza, pneumonia, and Hepatitis B vaccines as preventive services. These vaccines are covered by Part B if you have Original Medicare or a Medicare Advantage plan.

If you receive a Part B-covered vaccine after exposure to a dangerous disease, you will pay the normal cost sharing for Part B services. If you have Original Medicare, Medicare will cover 80 percent of the cost, and you or your supplemental insurance will be responsible for 20 percent once you have met your Part B deductible. If you have a Medicare Advantage plan, you will typically pay a copay for this service. Contact your Medicare Advantage plan directly to ask about specific vaccine costs. If you receive one of the three preventive vaccines covered under Part B, Original Medicare will cover the costs with no coinsurance or deductible, as long as you see a provider that accepts Medicare assignment. A Medicare Advantage plan will cover the costs with no coinsurance, copays or deductibles as long as you see an in-network provider.

All other vaccines are covered by Medicare Part D. Both Medicare Advantage prescription drug plans and stand-alone Part D plans must include all commercially available vaccines on their drug formularies, including the vaccine for shingles (herpes zoster).  However, for these vaccines covered by Part D, you may pay different amounts depending on where you get vaccinated. Check directly with your plan for coverage rules and costs.

In general, you will pay the least for a Part D-covered vaccine if you receive the shot at a pharmacy that is in your plan’s network, or at a doctor’s office that will bill your Part D plan directly for the cost of the vaccination process.  When you are at your doctor’s office, ask your doctor to call your Part D plan first to find out if there is a way that your doctor can bill your plan for the vaccine. There may be a way for the doctor to submit the bill so that you will not have to pay the whole cost up front.

If your doctor cannot submit the bill for the vaccine to your Part D plan through a partnering pharmacy, or cannot directly bill the plan for the drug, you may need to pay more for your vaccination. If this happens, your doctor will bill you for the entire cost of the vaccine, and you will have to pay the cost up front. Then you will have to follow your Part D plan’s rules to get a refund. Know that your doctor has no limit in how much they can change you for the vaccine, but your Part D plan will only pay its approved amount for payment. You will be responsible for the difference between the doctor’s charge and the plan’s approved payment amount.

If you have Extra Help, the federal benefit that helps people with low incomes pay for their prescription drugs, you can go to any doctor or in-network pharmacy for a vaccine. You will be covered for the vaccination and will only be responsible for the Extra Help copay.

-Marci