Allergy shots, formally known as subcutaneous immunotherapy, are a long-term treatment option for individuals who suffer from severe allergic conditions like chronic allergic rhinitis or asthma. This treatment involves a series of injections containing tiny amounts of specific allergens to gradually desensitize the immune system, reducing the body’s reaction over time. Medicare does generally cover allergy shots, provided a physician determines the treatment is medically necessary to manage the patient’s condition. Coverage for this outpatient service depends on the specific type of Medicare plan the beneficiary has chosen.
How Medicare Part B Covers Immunotherapy
Original Medicare’s medical insurance, Part B, provides foundational coverage for outpatient care, which includes allergy shots. For Medicare to cover this treatment, a physician must document that the allergy shots are medically necessary. This documentation usually requires showing that the patient’s symptoms, such as those from allergic rhinitis or asthma, are not adequately controlled by standard medications or environmental controls.
Part B covers both components of the subcutaneous immunotherapy: the preparation of the customized allergen serum and the administration of the shot by a healthcare professional. It is a requirement that the shots be given in a doctor’s office or clinic under the direct supervision of a healthcare provider. This ensures a trained individual is present to monitor the patient for any potential severe reactions, such as anaphylaxis. Immunotherapy delivered by sublingual means, such as tablets placed under the tongue, is generally not covered by Medicare Part B.
Once a beneficiary has met their annual Part B deductible, the federal program will pay 80% of the Medicare-approved amount for the allergy shot services. The beneficiary is then responsible for the remaining 20% coinsurance. Furthermore, coverage may be reviewed or discontinued after approximately two years if there is no observable clinical benefit, such as a reduction in symptoms or decreased need for other allergy medications.
Coverage Through Medicare Advantage Plans
Beneficiaries who receive their benefits through a Medicare Advantage plan, also known as Part C, will also find that allergy shots are covered. By law, these private insurance plans must provide at least the same level of coverage as Original Medicare Part A and Part B. The key difference lies in the way the costs and service rules are structured.
Unlike the 20% coinsurance model of Part B, Medicare Advantage plans often use fixed dollar copayments for services like specialist visits and injections. This means a patient might pay a set amount, such as $25 or $50, for each allergy shot visit, rather than a percentage of the total cost. The overall out-of-pocket costs can vary significantly from one Part C plan to another.
Most Part C plans operate with managed care networks, such as Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs). A beneficiary may be required to receive their allergy shots from an in-network allergist or clinic to obtain the lowest cost-sharing. Additionally, many Medicare Advantage plans require prior authorization before starting a long-term treatment like immunotherapy.
Understanding Your Out-of-Pocket Costs
For those with Original Medicare (Part B), the 20% coinsurance for every shot can accumulate quickly, particularly since allergy shots are frequent in the initial phase. Many beneficiaries with Original Medicare choose to enroll in a Medicare Supplement Insurance plan, or Medigap. Medigap plans are designed to fill the “gaps” in Part B coverage, specifically the 20% coinsurance, and can cover the full amount depending on the plan selected. Medigap plans do not work with Medicare Advantage plans.
For individuals with Medicare Advantage, costs are managed through copayments and an annual Maximum Out-of-Pocket (MOOP) limit. All payments for covered services, including allergy shots, count toward the MOOP limit. Once a beneficiary reaches this maximum, the plan pays 100% of all covered healthcare services for the remainder of the calendar year.
The allergy serum itself is considered a medical service covered under Part B or Part C, not a self-administered prescription drug. Therefore, Part D prescription drug coverage is generally irrelevant to the cost of the injection.