Does Medicare Part B Cover Vaccines ?

Coming into fall, it’s the time to start thinking about flu shots, and the other vaccinations that can help us to protect our elderly parents from nasty winter illnesses, and the serious health complications which come with these. You may only need to get just the flu shot for this season, but it helps to know what is, and what isn’t, covered by Medicare Part B.

Medicare Part B will cover the Influenza Vaccine, the Pneumococcal Vaccine, a series of 3 Hepatitis B shots (if you are at medium or high risk from hepatitis), and certain shots in the case of an injury or illness which make it medically necessary, such as a Tetanus Vaccine or Rabies treatment shots under certain circumstances.

Medicare Part B and Vaccines

To be able to get the vaccinations covered, you do have to be enrolled in Medicare Part B.

Under Medicare Part B, you will be covered for –

Influenza Vaccine 

Pneumococcal Vaccine 

Hepatitis B Vaccine – if you are in a situation of medium or high risk from infection.

Vaccines which are medically necessary as a result of injury or illness – for example, the Tetanus Vaccine if you have a puncture wound and may be at risk of developing a tetanus infection.

In the cases of the flu, hepatitis B and pneumonia shots, the vaccines are a cost free benefit, so long as you use a Medicare-enrolled Doctor, or other qualified health care provider, who accepts assignment, you have nothing to pay.

Once I have fully outlined the different vaccines that are covered by Medicare Part B, and how they are covered, I will be outlining what is available with Medicare Part C (Advantage Plans) and Medicare Part D (Drug Plans).

Medicare Part B and the Influenza Vaccine

If you are enrolled in Medicare, Part B will cover one flu shot per season, and so long as your physician or other qualified health care provide are Medicare-enrolled and accept assignment you have nothing to pay.

Under special circumstances if it is “medically necessary”, a person may be covered by Medicare Part B for more than one flu shot in a season. 

With the flu shots there is no deductible and as long as your provider accepts assignment there is no co-insurance. It’s all free.

Medicare recommends that everyone get the Influenza Vaccine each flu season.

Flu is a respiratory illness which is caused by the Influenza viruses, and is highly contagious.

You can catch the virus from an infected person as they talk, cough or sneeze, and they can be up to six feet away.

To a lesser degree, it may be possible to catch it by touching something which has the flu virus on it and then touching your mouth or your nose.

Someone who has the flu is thought to be able to infect others from the day before they realize they have it, and for the following 7 days.

The flu season is November to April.

For certain groups of people there is a greater risk if they catch the flu, and they are the following –

• the elderly
• young children under the age of 5
• people with certain underlying health conditions

Why should the elderly get flu shots ?

The elderly, and especially those with underlying health conditions, which I will outline in a moment are at the greatest risk, and should get their flu shot each year.

The flu shot should be given each year, as the virus mutates from season to season, often rendering the vaccine from the previous season ineffective for the new strains.

Carers and family, who frequently visit elderly loved ones, should themselves make sure they have had the flu shot, so they don’t catch it, or become contagious.

The elderly are recommended to be given higher dosage flu shots to provide them with greater protection – either High – Dose Flu Vaccine, or Adjuvanted Flu Vaccine

These few lines outline the case for why the elderly need to get immunized against the flu each year.

Each year in the United States, 9 out of 10 flu-related deaths and 6 out of 10 flu-related hospital stays occur among people aged 65+. An annual flu shot is one of the best preventive measures to help protect against the flu. The shot is available in both a regular strength dose and a high dose that provides extra immunity, which is often recommended for older adults.

The text is from NCOA Center for Benefits access – “Vaccines: What Medicare pays for” which you can read here.

The older a person is, who comes into contact with the flu virus –

• the more likely they are to catch the flu
• the more likely they are to develop serious complications from the flu, such as pneumonia
• the older they are, the more likely they are to have one or more underlying health conditions which can put them at even greater risk of serious complications

Underlying medical conditions which can put the elderly, or younger adults, at increased risk of complications should they catch the flu, include –

• heart disease
• asthma or COPD
• diabetes
• liver or kidney disease
• a compromised immune system – cancer treatments, HIV/AIDS, steroids, anti-inflammatory treatments can all make the immune system vulnerable to the flu virus

What are the different types of flu vaccine ?

There are a number of standard Influenza Vaccines available to adults  –

• Quadrivalent Influenza Vaccine
• High-Dose Flu Vaccine
• Intradermal Influenza Vaccine
• Adjuvanted Vaccine
• Cell-based Flu Vaccine
• Recombinant Flu Vaccines
• Nasal Spray Vaccine

For the over 65’s the recommended vaccines are –

• High-Dose Flu Vaccine
• Adjuvanted Vaccine

This information is from the Centers for Disease and Prevention website and you can check it here if you wish to learn more.

Does Medicare Part B cover the quadrivalent flu vaccine ?

Quadrivalent flu vaccines protect against 4 different strains of the flu virus at the same time.

Below is a list of influenza quadrivalent vaccines from the Centers for Medicare and Medicaid Services which are covered in the 2020-2021 flu season.

• Fluad Quadrivalent
• Fluzone High-Dose Quadrivalent
• Flucevax Quadrivalent
• FluMist Quadrivalent
• Flubok Quadrivalent
• Fluzone Quadrivalent
• Afluria Quadrivalent
• Fluarix Quadrivalent
• Flulaval Quadrivalent

The list is from here on the Centers for Medicare and Medicaid Services.

Does Medicare pay for flu shots at a pharmacy ?

Medicare Part B will cover flu shots at pharmacies if they are Medicare-enrolled and accept assignment, and of course you have to enrolled in Medicare Part B also.

With the flu vaccines you do not have to pay a deductible, and if the pharmacy accepts assignment you do not have to pay any coinsurance.

Pharmacies such as Walgreens, Walmart, Costco, Rite Aid, CVS, and Kroger all give flu shots which are covered by Medicare Part B.

You should always check with the pharmacy to make sure that they are Medicare-enrolled, and they accept assignment, which means they accept the Medicare-approved price for the vaccine.

The pharmacies which are Medicare-enrolled and accept assignment should bill Medicare directly, and you will have nothing to pay.

You must ask the pharmacist to forward the information on the vaccination to your primary care doctor to keep your records up to date.

What does a flu shot cost without insurance ?

If you don’t have insurance the price of flu jabs can vary according to state, but it ranges for $20.00 to $50.00 on average depending on your state and your provider. 

In some cases it may be even higher.

How does Medicare Part B cover  pneumonia shots ?

As I said at the beginning of this article, Medicare Part B does cover the pneumococcal vaccine.

If you are enrolled in Medicare, the two vaccines are a cost free benefit, so long as you use a Medicare-enrolled Doctor, or other qualified health care provider, who accepts assignment.

There are two types of pneumococcal vaccine given in the US –

• Pneumococcal Conjugate Vaccine (PCV13)
• Pneumococcal Polysaccharide Vaccine (PPSV23) or Pneumovax 23

Medicare offers a first vaccine, and if it is considered medically necessary by your physician, you may be able to  receive the second pneumonia shot no less than one year later.

Elderly adults with underlying health conditions may need to have a booster vaccine once every 5 years. 

The two vaccines protect against different strains of the pneumococcal bacteria. 

What are pneumococcal bacteria,  and pneumonia ?

Pneumococcal bacteria infections are responsible for a number of different illnesses –

• ear infections
• sinus infections
• pneumonia
• meningitis

The Centers for Disease Control and Prevention recommends that all over 65’s get the pneumococcal vaccine.

It is possible to get the pneumococcal vaccine and the flu vaccine at the same time.

People with pneumonia infections can develop other very serious complications, including –

• bacteria which spread into the bloodstream, causing organ failure
• infections in the fluid build up in the lungs
• lung abscess, needing surgery or drainage

You don’t want to be battling such illnesses at an advanced age.

The CDC recommends that –

For adults 65 years or older who do not have an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant and want to receive PPSV23 ONLY:

 

• Administer 1 dose of PPSV23.

   

  • Anyone who received any doses of PPSV23 before age 65 should receive 1 final dose of the vaccine at age 65 or older. Administer this last dose at least 5 years after the prior PPSV23 dose.

  For adults 65 years or older who do not have an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant and want to receive PCV13 AND PPSV23:

  • Administer 1 dose of PCV13 first then give 1 dose of PPSV23 at least 1 year later.
    • Anyone who received any doses of PPSV23 before age 65 should receive 1 final dose of the vaccine at age 65 or older. Administer this last dose at least 5 years after the prior PPSV23 dose.
    • If the patient already received PPSV23, give the dose of PCV13 at least 1 year after they received the most recent dose

The passage “Pneumococcal Vaccination: Summary of Who and When to Vaccinate” is here on the CDC website.

Does Medicare pay for Pneumonia shots at a pharmacy ?

Pneumococcal vaccine shots in pharmacies are covered by Medicare Part B, if you are enrolled in Medicare and  the pharmacy is Medicare-enrolled and accepts assignment – this means they accept the Medicare-approved price for the vaccine.

Under these circumstances, the pharmacy will usually bill Medicare directly, and you have nothing to pay at all.

With Medicare Advantage, you just have a pharmacy in the plan’s network, and you won’t have anything to pay.

How much does it cost to get a pneumonia shot ?

If you don’t have insurance for your pneumonia shots, the CDC lists the prices in the private sector,  for the autumn of 2020, as –

• PCV13 – $202.00
• PPSV23 – $105.19

You can check the cost of most vaccines in the private sector here on the CDC website.

Does Medicare cover the Hepatitis B Vaccine ?

Medicare Part B covers Hepatitis B shots if the person is at Medium or high risk of Hepatitis B.

If your doctor or other qualified health care provider is Medicare-enrolled and accepts assignment, you will pay nothing.

Accepting assignment simply means they accept the Medicare-approved price for the Hepatitis shots.

Medicare, on their website Medicare.gov states that –

Your risk for Hepatitis B increases if one of these applies:

• You have hemophilia.
• You have End-Stage Renal Disease (ESRD).
• You live with someone who has Hepatitis B.
• You’re a health care worker and have frequent contact with blood or bodily fluids.

You can see the text here on the Medicare site.

Medicare also notes that there can be other factors which may make you a candidate for Hepatitis shots, so do check with your doctor to see if you think you are a medium or high risk case.

What exactly is the Hepatitis B ?

Hepatitis B is a disease is spread by the hepatitis B virus, which affects the liver and which is generally spread through bodily fluids.

Hepatitis B are is not always serious, sometimes it is mild and may last only a few weeks, but it can cause severe illness which can have life changing effects on your health.

The hepatitis B virus is what spreads the hepatitis disease, generally  through bodily fluids.

Hepatitis B affects the liver.

There is a mild form of hepatitis B called “Acute Hepatitis B Infection”, and a

chronic form of hepatitis B is called “Chronic Hepatitis B Infection”.

Chronic Hepatitis B Infection – the virus remain in the infected person’s body, which may cause cirrhosis of the liver, cancer, and ultimately death.

People with the chronic form are spreader of the hepatitis B virus, and can give it to others in their bodily fluids.

The disease is more dangerous for certain individuals who may have other health conditions.

Individuals who are at greater risk are people with –

• hemophilia
• end stage renal disease
• diabetes
• health conditions which compromise the immune system

To get the full protection against Hepatitis B, you need the series of three shots against the virus.

You can read more about the Hepatitis B virus, you can go to Centers for Disease Control and Prevention here.

The Hepatitis Vaccine

Hepatitis B vaccine is a series of 2, 3 or 4 shots, typically given over a period of 6 – 9 months.

If you get the full vaccination – all the shots – it is thought to last at least 20 to 30 years, if not longer.

The Centers for Disease Control and Prevention recommend that the following unvaccinated adults receive the vaccine –

• People whose sex partners have hepatitis B
• Sexually active persons who are not in a long-term monogamous relationship
• Persons seeking evaluation or treatment for a sexually transmitted disease
• Men who have sexual contact with other men
• People who share needles, syringes, or other drug-injection equipment
• People who have household contact with someone infected with the hepatitis B virus
• Health care and public safety workers at risk for exposure to blood or body fluids
• Residents and staff of facilities for developmentally disabled persons
• Persons in correctional facilities
• Victims of sexual assault or abuse
• Travelers to regions with increased rates of hepatitis B
• People with chronic liver disease, kidney disease, HIV infection, infection with hepatitis C, or diabetes
• Anyone who wants to be protected from hepatitis B

The list of people at risk comes from this statement on the CDC website here.

Hepatitis B Vaccines available are –

• Hepislav-B 
• Energix-B 
• Recombivax HB
• Twinrix

Under what circumstances does Medicare Part B cover the Tetanus Vaccine ?

If you have an illness or injury, Medicare Part B or Medicare Part C, will cover the Tetanus Vaccine as “medically necessary” if it is prescribed by a Medicare-enrolled doctor.

To be covered for the Tetanus Vaccine under normal circumstances you need to be enrolled in a Medicare Part D plan.

Does Medicare Part C or Medicare Advantage cover Vaccines ?

Medicare Advantage Plans, or Medicare Part C as it is also known, are required to give the same coverage as Original Medicare Parts A and B.

This means that they must cover in the same way the different vaccinations that are covered by Medicare Part B, in the same way as I have described above.

This means, that as long as you use a provider who is in your Advantage Plan network, as advised by your plan, and you meet the Medicare eligibility requirements for the vaccine, you will pay no deductible or co-insurance.

As well as the vaccines that Medicare Part B covers, some Advantage Plans also cover the Shingles vaccine, and both forms of Tetanus booster.

You will have to consult with your provider to find out, whether, your plan  covers the shingles or tetanus vaccines, and what are the payment conditions, as Original Medicare does not cover this, so your plan will have its own rates of co-insurance that you will have to pay. 

Medicare part D vaccines and Vaccine administration 

Medicare Part D cover drugs, and as part of this it covers commercial vaccinations which are not covered by Medicare Part B.

Commercially available vaccines will include a lot of the shots that are needed for travel abroad for vacations and business trips.

Part D plans are all different and will have different rates and co-pays for the vaccines that they offer.

According to the Centers for Medicare and Medicaid Services –

• Medicare Prescription Drug Plans (Part D) cover all commercially available vaccines, except those covered by Medicare Part B.
• Part D plans should not charge separate co-payments for the vaccine and its administration.
• Patients may need to pay their the prescriber upfront for Part D vaccines, and submit a claim to their Part D plan for reimbursement.
• Prescribers must discuss the charges for a vaccine before it is administered so that patients may check it against the amount their plan will cover.
• If a patient has a vaccine which costs above the amount covered by their plan and did not contact them beforehand, they will have to pay the difference out of pocket.
• If a patient has the vaccine administered in a pharmacy which is in the plan network, they will take a prescription to the pharmacy, and after the vaccine is administered, the pharmacy will bill the Part D plan, and the patient pays the pharmacy the required co-pay for their plan
• In the case that the pharmacy provides the vaccine to the prescriber to be administered, the pharmacy receives and fills the prescription. After which the prescription is sent to the prescriber, who then administers the vaccine. The pharmacy bills the Part D plan for dispensing the vaccine, and the patient also pays the pharmacy their Part D cost share. The patient will then pay the prescriber for administering the vaccine, and after which they can submit a claim for the reimbursement to their Part D plan, for the prescriber’s charge for  administering the vaccine.

Does Medicare Part D cover the Shingles Vaccine ? 

The Shingles Vaccine, Shingrix is covered by Medicare Part D plans

• Shingrix is recommended for adults over the age of 60
• the amount of the copay for the Shingrix Vaccine will vary with each provider
• your Medicare Part D plan will have its own rules for administration, payment and in-network usage
• The Shingles vaccine Zostavax was removed from the US on the 1st of July 2020

To learn more about the Shingles vaccine, got to the Centers for Disease Control and Prevention website here.

What is shingles  ? 

Adults over 50, and especially adults over 80, are most prone to getting shingles, and individuals with a compromised immune system are at greater risk of getting shingles.

In Shingles, a virus causes a rash which may appear on any part of your body.

Shingles is caused by the virus which gives us chickenpox – the varicella-zoster virus.

If a person has had the chickenpox, the virus will lie dormant in nerve tissue and reactivate as shingles many years in the future.

Shingles appear as a rash which may appear on any part of your body.

The rash will then blister and  become extremely painful to touch, and causing movement to be very unpleasant.

My mom had shingles in her  eye at 88 years old, and it truly was a nightmare for her.

Mom had constant pain in the eye and headaches for around 6 months, and really unable to do much other than rest or sleep.

Long after you have recovered from the actual virus, shingles may leave you with long term nerve pain, numbness and tingling, – this condition is called Neuralgia or Neuropathy.

Prior to July 2020 the two main Vaccines for shingles in the US were –

• Zostavax
• Shingrix

Shingrix has been more successful in protecting people from getting shingles.

The CDC recommends that all the over 50s to get the Shingrix Vaccine for shingles.

What is Tetanus ?

Spores of bacteria, called Clostridium tetani, when they enter the body make a toxin which causes the tetanus infection.

After the spores enter the body, they develop into bacteria, and produce the toxin tetanospasmin.

These spores are found all around us, and can enter the body through breaks in the skin, such as puncture wounds, or wound which become infected.

Tetanus can lead to problems with swallowing, muscles spasms, headache, fever, and can ultimately lead to death.

It is important to get the tetanus vaccine if you haven’t had it, and to get the booster once every ten years.

Does Medicare Part D cover Tetanus shots ? 

Medicare Part D plans cover tetanus booster shots for adults when it is not an emergency and for an illness or injury (in the case of an injury or illness, and it is prescribed as “medically necessary” it is covered by Medicare Part B)-

• the Tdap  and Td Vaccines are for tetanus, diphtheria and pertussis (whooping cough)
• the amount of the Tdap or Td Vaccine co-pay will depend on the plan that you have enrolled in
• your Medicare Part D plan will have its own rules for administration, for payment and for in-network use

What is the Tetanus Vaccine ? 

Infants are vaccinated with a vaccine known a DTaP, which is spread over a series of inoculations over roughly a 6-year period.

5 years after the first series is completed, the child receives a booster vaccine called Tdap.

For adults, The Center for Disease Control and Prevention (CDC) advises –

All adults who have never received one should get a shot of Tdap. This can be given at any time, regardless of when they last got Td. This should be followed by either a Td or Tdap shot every 10 years.

You can find the whole document on their website here.

The other sources for this passage on tetanus and the vaccines for tetanus were –

Mayo Clinic article on Tetanus, which you will find here.

A document on the Centers for Disease Control and Prevention (CDC) website which you will find here.

Does Medicare Part D cover Yellow Fever Vaccine ? 

Medicare Part D covers all commercially available vaccines which are not covered by Medicare Part B, and this includes vaccines for foreign travel.

Yellow Fever is covered by Part D plans, along with other tropical disease vaccines..

The amount of your co-pay will vary according to the plans available.

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To Summarize 

Medicare Part B covers –

The Influenza vaccine  –

• Medicare Part B will cover one flu shot per flu season
• additional flu shots may be covered if it is considered medically necessary
• there is no to pay co-insurance or deductible as long as the practitioner and provider accept assignment
• you can get your shots at a pharmacy, but they must accept assignment

The Pneumococcal (pneumonia) vaccine

• Medicare Part B pays for the pneumococcal vaccine
• if it is medically necessary for people with underlying health conditions, there is a 5 yearly booster
• there is no deductible for pneumonia shots and no co-insurance if the provider accepts assignment
• you can get your shots at a pharmacy, but they must accept assignment

The Hepatitis B Vaccine –

• Medicare Part B will pay for a series of 2- 4 shots for high or medium risk individuals
• there is nothing to pay, so long as the health care provider for the Hepatitis B Vaccine accepts assignment 

The Tetanus Vaccine –

• Medicare Part B will cover the Tetanus Vaccine in the case of an injury or illness, if it is “medically necessary” and prescribed by a Medicare-enrolled physician

Medicare Part C (Medicare Advantage) covers –

• Medicare Part C will by law have to cover the same services as Original Medicare Parts A and B, so they all cover the Influenza Vaccine, the Pneumococcal Vaccine, the Hepatitis B Vaccine and in the case of an injury or illness the Tetanus Vaccine
• if there is no deductible or so-insurance to pay with Medicare Part B, then there will not be with Part C either – always check with your plans who you can use to get the vaccines, as you must stay in-network to get all the coverage
• some Medicare Part C plans may cover the Shingles Vaccine as an extra benefit

Medicare Part D covers –

The Shingles Vaccine – 

• Part D plans covers Shingrix which is recommended for adults over the age of 60
• the amount to which they cover the Shingles Vaccine will vary with each provider
• the amounts of the co-pay will depend on your Medicare Part D plan
• each Medicare Part D plan will have its own rules for administration and for payment – what you pay, who you pay, and when you, also depends on if you have your shots in a pharmacy, or at the doctors
• you can get shots in a pharmacy with Medicare Part D

The Yellow Fever Vaccine and similar vaccines for travel –

• Part D plans cover all vaccines not covered by Medicare Part B
• Part D covers all commercially available vaccines, including those for travel
• coverage and reimbursement will depend on the plan you enroll in
• each Medicare Part D plan will have its own rules for administration and for payment – what you pay, who you pay, and when you, also depends on if you have your shots in a pharmacy, or at the doctors
• you can get shots in a pharmacy with Medicare Part D

The Tdap Vaccine –

• the Tdap vaccine is for tetanus, diphtheria and pertussis (whooping cough)
• Part D plans pay for adults to have the Tdap vaccine (children get the DTaP Vaccine)
• how much Tdap your co-pay is, will depend Medicare Part D plan that you have signed up to
• each Medicare Part D plan will have its own rules for administration and for payment – what you pay, who you pay, and when you, also depends on if you have your shots in a pharmacy, or at the doctors
• you can get shots in a pharmacy with Medicare Part D