Question: My doctor recommended vaccines for this fall, how are they covered by Original Medicare?

Answer: Vaccines and injections prescribed by our physicians are covered differently depending on what the injection is for. Original Medicare Part A would cover any injection given as part of a hospital stay. Medicare Part B covers outpatient services including some injections and vaccines; the Flu shot, Hepatitis B, Pneumococcal and COVID-19. These vaccines are administered either in a doctor’s office, health clinic or pharmacy and are covered in full by Medicare Part B with no deductible and no 20% cost share.

Other immunizations and injections are covered by Medicare Part D. Medicare Part D is the prescription drug coverage insurance that you purchased or enrolled in separate from or in addition to your Medicare Part A & B. The Part D coverage includes vaccines like shingles, MMR (measles, mumps and rubella), DPT (diphtheria, pertussis and tetanus) and RSV (Respiratory Syncytial Virus). In this situation your Part D plan would place these medications into a tier (1, 2, 3, 4, or 5), but any vaccines that are recommended by the Advisory Committee on Immunization Practices (ACIP) are covered in full with NO cost share to you, as long as you have a Part D plan.

When your doctor advises getting these vaccines, you can be comfortable knowing that most common vaccines have no cost share once you are enrolled in Medicare and a Part D plan.

An injection that does not fit this previous illustration but is covered under Part D is Denosumab (brand name-Prolia). Denosumab is an injection that you get once every 6 months. This injection is covered by your Part D insurance plan and therefore is subject to those different cost structures in the phases of coverage. Another issue with the Denosumab injection is that it is considered a 6 month supply of the medication. The insurance company cannot bill you for 6 co-pays, so you actually pay the three month supply cost structure. That could mean a significant cost for the injection even when you are in coverage. To help illustrate; The Denosumab shot retail costs roughly $1300. So, the deductible could be up to $590 and then it would move into the Initial Coverage and the cost is based on the Tier (usually Tier 3 or 4). This cost could range from $47 to 33% ($1300×33%=$429) in most of the plans. That is a big swing in price depending on your plan. This injection is also a multiple month’s supply, so you could be charged up to three months of co-pay for that single injection. ($42×3=$126 or $429×3=$1287). In catastrophic phase, as with all medications, the cost goes to $0.

If you have a Medicare Advantage Plan your immunizations/injections are covered, but you might not be informed of how it is being covered (outpatient vs pharmacy) at the time of purchase. The insurance company would file it with the appropriate type of coverage (Outpatient vs Part D) and your co-pays structure would follow the same protocols as listed above.

You also may have EPIC (Elderly Pharmaceutical Insurance Coverage) which would be secondary to your Part D plan. This could help cover the cost of immunizations and injections billed via your Part D coverage.

I am happy to hear that your physician and you are discussing immunizations and hopefully other preventative measures and tests. Many of these preventative care items are covered in full by Original Medicare and your Medicare Advantage Plan. But if you ever have questions about this type of coverage, you can of course reach out and ask me, but you also have the resources of your Medicare and You Handbook which Medicare publishes and sends to you each year, the www.Medicare.gov website which has excellent resources to evaluate, or call Medicare at 800-MEDICARE (63342273). If you have a Medicare Advantage Plan, you can call your insurance company at the number on the back of your insurance card.