What vaccines does Medicare not cover?
Vaccines are important for preventative healthcare. They help stop the spread of sickness, keep you healthy, and prevent long-term consequences of certain diseases. Depending on the service, your prescription drug plan (Part D) or Medicare Part B will cover many vaccines, but there are some that Medicare doesn’t cover.
In this article, we’ll discuss what vaccines Medicare does and does not cover, and how you can get coverage for the preventative services you need.
Key takeaways:
Medicare generally covers vaccines that are reasonable and necessary to prevent illnesses.
Medicare does not cover travel vaccines like yellow fever and typhoid, but every plan is different. Check with your provider or drug formulary to see which vaccines you won’t have to pay for.
Medicare Part B and Part D (prescription drug coverage) are responsible for covering different vaccines.
What vaccines does Medicare Part B cover?
While it doesn’t cover all vaccines, Medicare Part B is the insurance that pays for doctor visits, outpatient care, and preventative services like vaccines. Here’s what shots Medicare Part B covers:
Pneumonia
Hepatitis B for people who are at high risk of infection
COVID-19
Other vaccines you need to treat an injury or exposure to a disease (like the tetanus shot)
Some vaccines may only be reserved for people with certain health conditions or who are more likely to be immunocompromised. For example, people with chronic lung disease, heart disease, or diabetes may have more vaccines covered.
What vaccines does Medicare Part D cover?
Before 2023, beneficiaries had to pay for copayments associated with vaccines that weren’t covered by Medicare Part B. The Inflation Reduction Act eliminated all out-of-pocket costs for vaccines that are recommended by the CDC. These vaccines include:
Your prescription drug formulary will include most commercially available vaccines, but check with your plan if you’re ever unsure about what it covers.
What vaccines does Medicare Advantage cover?
Medicare Advantage plans have to cover the same services that Original Medicare does. That means that any preventative vaccine that Original Medicare pays for, like the flu and COVID-19 shots, must also be covered by Medicare Advantage plans.
Part D plans can be standalone policies or can be bundled into Medicare Advantage plans. Anyone who has a Medicare Advantage plan that includes Part D insurance coverage will have the shingles, RSV, and other shots included in the plan covered.
Note that, if you’re on a Medicare Advantage plan, you may have to pay some costs for a vaccine if you receive it from an out-of-network provider.
What vaccines does Medicare not cover?
For the most part, Medicare does not cover vaccines for travel purposes. These include yellow fever or typhoid shots. Coverage for travel vaccinations can vary from plan to plan, however. If you have secondary insurance, for example, your secondary provider could cover the vaccine. Always contact your insurance provider ahead of time to make sure you know what to expect before getting vaccinated.
Prescription drug plans are optional—Medicare doesn’t require you to enroll when you’re first eligible for the insurance. You need to be enrolled in Part D to receive coverage for vaccines that are covered by a prescription drug plan. Otherwise, Medicare does not cover the shingles, RSV, and other vaccines.
Important notes:
The drugs that Part D covers vary from plan to plan. The RSV shot may not already be on the list of drugs (called a formulary) provided by your insurance. If this is the case, you can contact your insurance provider and ask for coverage exception. If you pay for the shot yourself, you can also contact your plan to get reimbursed.
Fixing gaps in your coverage is part of what we do here at Chapter. Our licensed Advisors get a sense of your unique healthcare needs and find what’s best for you—whether that’s enrolling in Part D or finding a plan that better suits your needs. Chat with us at 855-900-2427 or schedule a time to talk at your convenience.