Question: Why wasn’t the tetanus shot I received covered by Original Medicare?

Answer: Vaccine 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) and DPT (diphtheria, pertussis and tetanus). In this situation your Part D plan would place these medications into a tier (1, 2, 3, 4, or 5) and the phase of coverage (deductible, initial, coverage gap, or catastrophic) you were in would determine your cost share.

Some situations may change the way certain injections are covered. Tetanus is a good example. If you receive a Tetanus shot as a response to an injury, the Tetanus shot administered to you would be covered under Medicare Part B. If you receive a Tetanus shot because you haven’t had one in a long time (more than ten years) the injection would not be covered by Medicare Part B. Your physician’s office would be considered out of network for this billing- because the office is not considered a pharmacy. Instead, you would have to file a claim to receive reimbursement from your Part D plan. That reimbursement would be based on using an out of network provider, and would therefore reimburse you a lesser amount than it cost.

Another injection covered under Part D is denosumab. 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 $445 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 $42 to 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 the coverage gap the cost structure changes to 25% ($325) and during catastrophic cost is move to 5% ($65). When the insurance company processes as a multiple month supply, the cost could be three times this amount.

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). The insurance company would file it into the appropriate type of coverage 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.

In reviewing your Tetanus shot, I would advise calling whomever administered it and asking them to rebill it according to the previous coverage description. It may be corrected that way and your cost share would be reduced.

Senior Life Matters is a community based program sponsored by Lutheran Jamestown. For questions and concerns or to reach Janell Sluga, GCMC, call (716) 720-9797 or e-mail SLM@lutheran-jamestown.org.