Medicare's coverage includes vaccinations and immunizations?
In the ever-evolving landscape of healthcare, understanding the coverage of vaccines under Medicare is crucial for beneficiaries. Here's a breakdown of what's covered and how to request coverage for vaccines not typically found in Medicare Part D formularies.
Medicare Part B covers a range of vaccines, including those for flu (influenza), pneumonia, hepatitis B, COVID-19, and tetanus and rabies shots in certain circumstances. Premiums for Medicare Part B vary by individual income, with a base beneficiary premium of $185 per month in 2025. Notably, Medicare Part B covers 95% of the cost of most vaccines once a person meets their deductible ($257 in 2025), except for the flu vaccine which is fully covered.
On the other hand, Medicare Part D covers shingles, respiratory syncytial virus (RSV), hepatitis A, chickenpox (varicella), tetanus, diphtheria, and acellular pertussis (Tdap) vaccines. There are usually no out-of-pocket costs for these vaccines as long as they are recommended by the Centers for Disease Control and Prevention (CDC). However, vaccines covered under Medicare Part B, such as influenza, pneumococcal, and COVID-19 vaccines, are typically not covered under Part D.
If a vaccine is not included in the Part D plan’s formulary, it is considered an "Excluded Drug," meaning the cost does not count towards out-of-pocket totals, and no extra help is available to cover it. In such cases, beneficiaries can request coverage through a formulary exemption or coverage determination process.
This process involves verifying non-coverage, requesting a coverage determination or exception, submitting a statement from your prescribing physician supporting the medical necessity of the vaccine, and adhering to the plan’s deadlines for decision-making. Plans provide instructions on where and how to submit these requests, and they must provide timely decisions on exceptions.
Under Medicare Advantage (Part C), beneficiaries will get the same coverage for vaccines covered under Parts B and D. The average monthly premium for Part C plans is around $17.00 in 2025. It's essential to note that under Medicare, copayments usually apply to prescription drugs, not vaccines.
For those planning international travel, it's worth noting that Medicare Part D may cover travel vaccines recommended by the CDC’s Advisory Committee on Immunization Practices (ACIP), such as yellow fever, Japanese encephalitis, and chikungunya vaccines. However, if a newly approved travel vaccine is not on the formulary, beneficiaries can still request coverage through the formulary exemption process.
In summary, vaccines not on Medicare Part D formularies, particularly those covered under Part B or newly approved vaccines, can be requested for coverage via an exception process. This requires a physician’s supporting statement, submission to the plan, and adherence to the plan’s deadlines for decision-making. For more information about your specific plan’s coverage for vaccines and immunizations, beneficiaries are encouraged to contact Medicare directly.
- While Medicare Part B covers a range of vaccines, some vaccines are covered under Medicare Part D, such as shingles, respiratory syncytial virus (RSV), hepatitis A, chickenpox (varicella), tetanus, diphtheria, and acellular pertussis (Tdap) vaccines.
- Vaccines not included in the Part D plan’s formulary can be considered "Excluded Drugs," meaning the cost does not count towards out-of-pocket totals, and no extra help is available to cover it.
- In such cases, beneficiaries can request coverage through a formulary exemption or coverage determination process, which includes verifying non-coverage, requesting a coverage determination or exception, submitting a statement from your prescribing physician supporting the medical necessity of the vaccine, and adhering to the plan’s deadlines for decision-making.
- For those planning international travel, Medicare Part D may cover travel vaccines recommended by the CDC’s Advisory Committee on Immunization Practices (ACIP), but if a newly approved travel vaccine is not on the formulary, beneficiaries can still request coverage through the formulary exemption process.
