Medicare is the federal health insurance program primarily for people aged 65 or older, though it also covers some younger individuals with specific disabilities or conditions. Vaccine coverage under this program can be complex because it is split between different parts of Medicare. The specific part of the program that pays for a vaccine depends on the type of vaccine and its classification. This division means that how much a person pays out-of-pocket can vary significantly based on the vaccine being administered.
Preventive Vaccines Covered by Medicare Part B
Medicare Part B, which is considered Medical Insurance, covers certain vaccines categorized as preventive services. These services are generally provided to the patient at no cost, which is intended to encourage the prevention of highly transmissible or severe diseases. The patient pays nothing for the vaccine or its administration if the provider accepts Medicare assignment.
The annual influenza, or flu, shot is covered once per flu season, typically starting in the fall. Part B covers any flu vaccine approved by the Food and Drug Administration (FDA), including the higher-dose options recommended for older adults. The pneumococcal vaccine, which protects against certain types of pneumonia, is also covered under Part B. Medicare covers the first pneumococcal shot and a second, different shot one year later, if recommended by current vaccination guidelines.
Coverage for the Hepatitis B vaccine is available through Part B only for individuals who are classified as being at high or intermediate risk for the virus. This risk determination includes people with end-stage renal disease, hemophilia, or those with diabetes aged 60 and older. For those who qualify, the vaccine is covered at 100% of the Medicare-approved amount.
Vaccines Covered Under Medicare Part D
Medicare Part D provides prescription drug coverage through private insurance plans and covers most commercially available vaccines not covered under Part B. The primary vaccines falling under Part D include the recombinant zoster vaccine (Shingrix) for shingles and the Tdap vaccine, which prevents tetanus, diphtheria, and pertussis (whooping cough). Before recent legislative changes, Part D coverage meant the patient was subject to the plan’s deductible, copayments, and the various coverage phases of a drug plan.
Due to the Inflation Reduction Act (IRA), Part D plans must now cover all adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) with zero cost-sharing. This provision eliminates the deductible and copayment for vaccines like Shingrix and Tdap. The Shingrix vaccine, which is given as a two-dose series, was previously a significant out-of-pocket expense for many beneficiaries.
This change ensures that ACIP-recommended vaccines under Part D are as accessible as those covered under Part B. Part D plans include these vaccines on their formulary, or list of covered drugs. Any other vaccines that are not ACIP-recommended or not covered by Part B would still be subject to the standard Part D cost-sharing structure, which varies widely between private plans.
Patient Costs and Where to Receive Vaccinations
The administrative process of obtaining a vaccine under Medicare depends on whether it is a Part B or a Part D covered service. Part B vaccines, such as the flu and pneumonia shots, are typically administered in a doctor’s office or clinic setting. Since these are considered preventive services, you pay nothing if the healthcare provider accepts Medicare assignment, which is the agreement to accept the Medicare-approved amount as full payment.
In contrast, Part D vaccines like the shingles shot are usually obtained at a retail pharmacy. For ACIP-recommended vaccines, the out-of-pocket cost is now zero, meaning the patient pays no deductible, copayment, or coinsurance. It is important to confirm that the pharmacy is in-network with your specific Part D plan. Understanding this distinction between Part B’s medical coverage and Part D’s prescription drug coverage is the most important step for avoiding unexpected charges.