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Does Medicare Pay For Flu Shots At A Pharmacy ?

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The flu season will soon be on us again, and with Covid-19 out there as well, it is very important that our elderly loved ones get their flu shots to have some protection. One of the easiest ways to do this is to get it done is in a pharmacy.

Medicare Part B typically covers flu shots in a pharmacy if you are enrolled in Original Medicare, so long as the pharmacist, or other qualified health care provider, are Medicare-enrolled and accept assignment. There will be no deductible or co-insurance to pay.
 

Medicare reimbursement for flu vaccine ?

 

Do ask if the Pharmacy, pharmacist, doctor or other qualified health worker is Medicare-enrolled and that they accept assignment, as this means that you will be covered for the whole cost.

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

If the pharmacy is accepting assignment, they will typically bill Medicare directly.

Original Medicare will pay for one flu shot per season under the guidelines I have described.

If the pharmacy does not accept assignment and are not Medicare-enrolled, you will have to pay for the shot yourself, or with any other insurance that you may have.

If you don’t make an appointment at the pharmacy beforehand, you should take along a valid photo ID,  your proof of insurance, and you will have to fill out an assessment/consent form at the pharmacy.

Finally, ask the pharmacy to send the information on the vaccination to your primary care doctor to have your records updated.

 

What is the flu ?

 

The flu is a respiratory illness caused by Influenza Viruses which is highly contagious.

Each year there are what are called “seasonal flu outbreaks”, occurring from November to April.

These outbreaks are caused by Influenza viruses A and B.

A person who has the flu can pass it on when they talk, laugh, cough or sneeze to other people who are up to six feet away.

It may also be possible, but with a lesser frequency, to catch flu by touching your nose or mouth after you have touched a surface with the virus on it.

Infected people are at their most contagious during the first 3 – 4 days of the illness.

An adult may be able to infect other people from the day before the onset of the flu, and for another 7 days thereafter, which means that you can infect others even before you yourself know that you are sick.

The elderly, young children under the age of 5 and people with underlying health conditions are at the greatest risk from catching the flu.

There is lots of information on the flu on the Centers for Disease and Prevention website here.

Why should our elderly loved ones get flu shots ?

 

The following passage makes a compelling argument for elderly getting the flu vaccine 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 facts about aging are –

 

  • as you age, your immune system is less able to defend your body against infections and viruses
  • the older you are, the more likely you are to catch the flu when you come into contact with the virus
  • the older you are, the greater the chances are that you will develop serious complications from the flu, such as pneumonia
  • over 65’s with underlying medical conditions are at even greater risk of having serious complications from catching the flu

 

Having almost died from pneumonia at 31 yrs of age, I can only say that I would do all I could to avoid it at a more advanced age.

The underlying health conditions which put you at greater risk from serious complications include –

 

  • asthma or COPD
  • heart disease
  • diabetes
  • liver or kidney disease
  • a compromised immune system

 

Immune systems may be compromised by different types of cancer treatment, HIV/AIDS, steroids and different forms of anti-inflammatory treatments.

 

Two final points about getting vaccinated –

 

  • you need to get the vaccine each year, as the flu virus mutates and previous vaccines may no longer be effective the following season
  • when you get a flu shot, you are not only protecting yourself, but you are protecting those around you, and this is important for the caregivers, the children and the grandchildren of elderly adults

What are the basic types of flu vaccine available ?

 

The main types of Influenza Vaccines available to adults are –

 

  • Quadrivalent Influenza Vaccine – this protects against 4 different strains of viruses
  • High-Dose Flu Vaccine – this has 4 times more antigen than a normal vaccine to incite a stronger response from the body’s immune system
  • Intradermal Influenza Vaccine – this injected into skin instead of muscle
  • Adjuvant Vaccine – this is made with an additive to incite stronger immune response
  • Cell-based Flu Vaccine – the virus is grown in cultured cells of mammalian origin
  • Recombinant Flu Vaccines – these are made with a method not using eggs
  • Nasal Spray Vaccine – this is a live vaccine in a nasal spray

 

For the over 65’s, the following vaccines are recommended by the CDC –

 

  • High-Dose Flu Vaccine
  • Adjuvanted Vaccine

 

I took this information from the Centers for Disease and Prevention website, and you can find out more here.

 

Does Medicare cover the quadrivalent flu vaccine ?

 

The quadrivalent flu vaccines are one type of the vaccines that are covered by Original Medicare Part B.

Quadrivalent flu vaccines are designed to give protection against 4 strains of flu virus.

 

This is a list of quadrivalent vaccines from the Centers for Medicare and Medicaid Services which will be 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

 

If you wish to know more about the list you can find it here on the Centers for Medicare and Medicaid Services.

Does Medicare pay for flu shots at Walgreens ?

 

Original Medicare Part B does cover flu shots at Walgreens if –

 

  • you are enrolled in Original Medicare Part B
  • this is your only flu shot of the season

 

Walgreens is Medicare-enrolled and bills Medicare for the flu shot directly, and as I said above, there will be no deductible or coinsurance for you to pay.

If you are hoping to vaccinate a small child, the age restrictions will vary by state, but clinics will vaccinate children aged 2 yrs.

If you are not going to go to Walgreens for a shot don’t forget to take your insurance information, a photo ID and to complete the assessment/consent form – which if you want you can do in advance –  you can find and print out form the Walgreens website here.

If you want, you can book an appointment ahead on the Walgreens website here.

 

Without insurance at Walgreens

 

According to Flushotprices.com the cost of a flu shot at Walmart if you don’t have insurance in the fall of 2020 will be –

 

  • 2 – 65 yrs old  – per person –  $31.99
  • over 65 yrs old (high dosage) – per person – $54.99

 

Does Medicare pay for flu shots at Walmart ?

 

Original Medicare Part B does cover flu shots at Walmart.

 

To get your flu shot for nothing  –

 

  • you need to be enrolled in Original Medicare Part B
  • it must be your only flu shot in the flu season in question

 

Walmart is Medicare-enrolled and should bill Medicare for your flu shot.

As with all pharmacies which accept Medicare assignment, there will be no deductible or coinsurance for you to pay.

If you would like to book an appointment for a flu shot, you can do so on the Walmart website here.

 

Without insurance at Walmart

 

According to Flushotprices.com the cost of a flu shot at Walmart if you don’t have insurance in the fall of 2020 will be –

 

  • 2 – 65 yrs old  – per person –  $25.00
  • over 65 yrs old (high dosage) – per person – $48.00

 

Does Medicare pay for flu shots at CVS ?

Flu shots at CVS are covered by Original Medicare Part B if –

 

  • you are enrolled in Medicare Part B
  • you have had no other flu shots already in that particular flu season

 

CVS is Medicare-enrolled and accepts assignment and will normally bill Medicare directly for your flu shot, so you should have nothing to do.

Don’t forget to take proof of insurance and a valid photo ID with you when you go for your shot.

 

Without insurance at CVS

 

According to Flushotprices.com the price of a flu shot at CVS without insurance in the fall of 2020 will be –

 

  • 2 – 65 yrs old  – per person –  $31.99
  • over 65 yrs old (high dosage) – per person – $51.99

Does Medicare pay for flu shots at Costco ?

 

Costco’s flu shots are covered by Medicare Part B.

 

As with all the pharmacies –

 

  •  you must be enrolled in Medicare Part B
  • it has to be your only flu shot that season

 

Costco will bill Medicare for your flu shot, and there is no deductible or coinsurance for you to pay for the shot.

You don’t need to book an appointment for the flu shot, and can just walk straight on in, but you may have to wait if the pharmacist is otherwise occupied.

If you want to get the consent form completed ahead of time then you can visit their page for vaccines here, and download the consent form, or just locate your local Costco pharmacy.

Don’t forget to take proof of your Medicare insurance and a valid photo ID.

 

Without insurance at Costco

 

At Costco if you don’t have insurance in the fall of 2020 the cost of a flu shot, according to Flushotprices.com, will be –

 

  • 2 – 65 yrs old  – per person –  $14.99
  • over 65 yrs old (high dosage) – per person – $36.38

Does Medicare pay for flu shots at Rite Aid ?

 

Original Medicare Part B will cover flu shots at Rite Aid if –

 

  • you are enrolled in Medicare Part B
  • you have had no flu shots before in that particular flu season

 

Rite Aid is Medicare-enrolled and accepts assignment, so they should bill Medicare for your flu shot, and should be no deductible or coinsurance for you to pay.

You can get your shot without an appointment, but if you want to get the screening questionnaire and consent form filled out ahead of time, you can download it here on their website.

And again, don’t forget your insurance card and a valid photo ID.

 

Without insurance at Rite Aid

 

According to Flushotprices.com, for those without insurance, the cost of a flu shot at Rite Aid in the fall of 2020 will be –

 

  • 2 – 65 yrs old  – per person –  $31.99
  • over 65 yrs old (high dosage) – per person – $60.99

Does Medicare cover pneumonia shots ?

 

If you use a Medicare-enrolled doctor, or other qualified health care provider, who accepts assignment (the Medicare-approved price), Original Medicare Part B will cover two separate pneumococcal shots, and it’s free.

After having received the first pneumococcal vaccine, you have to wait at least one year before having the second shot, if your health care provider decides that it’s necessary.

 

The Pneumococcal Vaccine

The Centers for Disease Control and Prevention recommend for all adults over 65 to get the pneumococcal vaccine.

For those people who have certain underlying health conditions, it may be recommended to get it once every 5 years.

 

The following text is from the CDC –

 

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

You can read the whole document “Pneumococcal Vaccination: Summary of Who and When to Vaccinate” here on the Centers for Disease Control and Prevention website.

What vaccines are covered by Medicare ?

 

Vaccines covered by Medicare Part B –

The Influenza vaccine  –

 

  • one flu shot per flu season, which is the period from November to April
  • if it is considered medically necessary, additional flu shots may be covered
  • the Medicare deductible doesn’t exist for the flu shots
  • no co-insurance payment as long as the practitioner and provider accept assignment

 

The Pneumococcal (pneumonia) vaccine

 

  • Medicare pays for at least one shot
  • the vaccine is advised for all adults over the age of 65
  • when medically necessary for people with underlying health conditions, there is a vaccine booster every 5 years
  • the Medicare deductible doesn’t exist for pneumonia shots
  • no co-insurance payment if you use a practitioner and provider who accept assignment

 

The Hepatitis B Vaccine –

 

  • Medicare covers a series of three shots for high or medium risk individuals
  • so long as the health care provider for the Hepatitis B Vaccine accepts assignment, you will pay nothing

 

The Tetanus Vaccine –

If you suffer from an injury or illness, Medicare Part B will cover the Tetanus Vaccine so long as it is “medically necessary”, and prescribed by a Medicare-enrolled physician.

 

Vaccines covered by Medicare Part C (Medicare Advantage) –

 

  • Medicare Part C, or Medicare Advantage, covers almost all services provided by Original Medicare Parts A and B, including the Influenza Vaccine, the Pneumococcal Vaccine, the Hepatitis B Vaccine and in the case of an injury or illness the Tetanus Vaccine
  • each plan will have a specific network of providers, practitioners and suppliers, but if you use an in-network provider you will have nothing to pay, as with Medicare Part B
  • some Medicare Advantage plans cover the Shingles Vaccine and the two Tetanus boosters, so you will need to check that with your plan

 

Vaccines covered by Medicare Part D –

 

The Shingles Vaccine – 

  • Medicare Part D cover for Shingrix which is recommended by the CDC for all adults over the age of 60
  • Medicare Part D plan are all  different so the coverage of Shingrix will vary according to the plan
  • the amounts of your co-pay will also depend on your particular Part D plan
  • each Medicare Part D plan will also have its own rules for network use, the administering of the vaccine, and how you pay what you owe

Prior to the 1st of July 2020 there was a Shingles vaccine called Zostavax available in the US, but it has been removed from the market.

 

The Tdap Vaccine –

  • Tdap is for tetanus, diphtheria and pertussis (whooping cough)
  • Part D plans cover Tdap which is a Tetanus vaccine booster for adolescents and adults (children you get the DTaP Vaccine)
  • how much coverage  you will get for Tdap will depend on the Medicare Part D plan that you are enrolled in
  • each Medicare Part D plan will have its own rules for network use, the administering of the vaccine and for payment

 

Medicare Part D plans cover most commercially available vaccines, and for most diseases which are not covered by Medicare Part B.

Vaccines which are needed for vacations abroad, not by Medicare Part B, will be covered by Medicare Part D plans.

The deductibles and co-pays will vary with different plan providers.

To find out what the different vaccines will cost, you will have to contact the Medicare Part D plan provider.

What Medical equipment and supplies does Medicare cover ?

 

Medicare Part B gives coverage to what it calls “durable medical equipment”, or as DME for use in the home.

Medicare Part A – hospital coverage – covers any equipment or supplies used in a skilled nursing facility for a period of up to 100 days.

 

Equipment which is classed as Durable Medical Equipment by Medicare has to be:-

 

  • Durable (can withstand repeated use)
  • Used for a medical reason
  • Not usually useful to someone who isn’t sick or injured
  • Used in your home
  • Generally has an expected lifetime of at least 3 years

 

Source: Medicare.gov website – here.

For “use in the home” Medicare covers, amongst other things, wheelchairs, crutches and walkers, hospital beds, respirators, bedside commodes, patient lifts, and medical oxygen when they are medically necessary, in accordance with Medicare’s guidelines.

Items which Medicare considers  to be for convenience or comfort, or which are not primarily medical in nature, such as bath chairs, air purifiers, room heaters, grabbers, cold packs and massage devices, will not typically be covered.

 

Disposable medical supplies which are needed for use in association with durable medical equipment in the home will typically be covered by Medicare Part B.

Medical supplies which are disposable, and are not used in conjunction with a piece of durable medical equipment, are not covered by Medicare Part B.

 

Non-covered disposable medical supplies include the following –

 

  • bandages
  • face masks
  • elastic stockings
  • pressure leotards
  • support hose
  • surgical leggings
  • disposable sheets and bags
  • fabric supports
  • incontinence pads

 

Blood sugar strips and certain catheters may be covered by Medicare Part B if they are used in conjunction with durable medical equipment, and, or, for treating long term medical conditions.

For individuals receiving the Home Health Care Benefit, some disposable supplies needed will be covered.

Does Medicare Advantage cover flu shots ?

 

Medicare Advantage Plan are offered by private companies which have been contracted by Medicare to provide the same services as Medicare Parts A and B, so you will have the same coverage for vaccinations as Original Medicare.

You will of course have to find out which pharmacies are in the network that you may use.

If you don’t use a pharmacy in their network, you could find yourself paying for everything, but if you stay in-network, you will pay nothing.

Don’t rely on the pharmacy to know whether you are covered, you need to check with your plan provider.

As I noted earlier some Advantage plans also cover the Shingles vaccine, Shingrix, and the two Tetanus boosters, so if you are interested in that you need to check with your plan to see if you are covered and what the payment arrangements are for your co-insurance.

 

Free help with understanding Medicare

 

SHIP – State Health Insurance Assistance Programs

All States have SHIPs offering free counseling services on Medicare, Medicaid and Medigap.

I have a quick post outlining how to find your local SHIP, to contact them, and to get free help – “Free Help Understanding Medicare And Medicaid ? Here’s Where You Get It”.

Does Medicaid cover flu shots?

 

Each state is different with Medicaid, so it is difficult to say exactly what coverage is given to flu shots across the US, but if you qualify for Medicaid the following groups are covered –

 

  • children six months to four yrs old
  • women who will be pregnant during the flu season
  • children and adults who have compromised immune systems, including from HIV or medications
  • children and adults with lung, heart, liver, kidney disease, are undergoing cancer treatment or have diabetes
  • children between the ages of 6 months and 18 years who are undergoing long term aspirin therapy
  • residents of Medicaid state nursing homes and long term care facilities
  • adults over the age of 50

 

Medicaid will cover the cost of the flu shots.

There are also state age restrictions on flu shots which vary across the US, but this applies to small children and not to adults.

 

To find your State Medicaid State Agency

 

Should you need to email or talk with someone in your State Medicaid Administration, you can contact your state Medicaid Agency here.

Follow the steps below once the new window opens.

 

Step 1 –

Click the link to Medicaid.gov, look to the section I outlined in red.

 

Step 2 –

Just select your state and click on “GO” – it will take you to your State Medicaid Agency with all their contact information.

I’m Gareth and I’m the owner of Looking After Mom and Dad.com

I have been a caregiver for over 10 yrs and share all my tips here.

Gareth Williams

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