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What vaccines are covered by my Part D plan?

In your last newsletter you explained how Part B covers a few important vaccines. What vaccines are covered by Part D, though? I need to get the shingles vaccine and am hoping it won’t be too expensive.  

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Posted November 22, 2021 by at United States in Medicare
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If your provider recommends that you get a vaccine, in many cases it will be covered by your Part D plan. Part D plans must include most commercially available vaccines on their formularies, including the vaccine for shingles (herpes zoster). The only exceptions are flu, pneumonia, COVID-19, and hepatitis B vaccinations, which as we discussed in the last newsletter, are covered by Part B

The amount you pay for your vaccine may vary depending on where you get vaccinated. Be sure to check your plan’s coverage rules and see where you can get your vaccine at the lowest cost. Typically, you will pay the least for your vaccinations at: 

  • In-network pharmacies 
  • A doctor’s office that 
  • coordinates with a pharmacy to bill your Part D plan for the entire cost of the vaccination process (the drug and its injection) 
  • or, can bill your plan directly for the vaccination process using an electronic billing system 

When you are vaccinated in either of the above settings, you should only need to pay the plan’s approved coinsurance or copay for the drug and vaccination process. When you get a vaccine at your doctor’s office, ask the provider to call your Part D plan first to find out if your provider can bill your Part D plan directly. If this is possible, you should not have to pay the full out-of-pocket cost and later request reimbursement from your plan. 

You may end up paying more for your vaccination if your provider: 

  • cannot coordinate with a pharmacy to bill your Part D plan for the entire cost of the vaccination process (the drug and its injection) 
  • and/or, cannot bill your plan directly for the injection using an electronic billing system 

In these circumstances, your provider will bill you for the entire cost of the vaccination (the drug and its injection). You will have to pay up front and request reimbursement from your Part D plan. It is important to know that your provider may charge you more than the Part D approved amount for the vaccination, but your plan will only reimburse up to the approved amount—and you will not be refunded for any amount you pay the provider above the Part D approved amount. 

If you have Extra Help, you can go to any provider or in-network pharmacy to get vaccines. You will be covered for your vaccination and will only be responsible for the Extra Help copay. However, if you get your vaccine from a provider who does not directly bill your plan, you may need to pay the entire bill up front and then request reimbursement from your plan. 

-Marci 

Dear Marci is a free e-newsletter from the Medicare Rights Center (www.medicarerights.org), the nation’s largest independent source of information and assistance for people with Medicare. For more free answers to your Medicare questions, visit Medicare Interactive (MI) at www.medicareinteractive.org. Subscribe to Dear Marci by registering for your free account on Medicare Interactive. 

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Added: November 22, 2021