Most vaccinations or inoculations are excluded under the Medicare Part B
medical benefit. The only preventive vaccines covered under the member's Part B
benefit are pneumococcal, influenza virus, and Hepatitis B (for those who are
at high or intermediate risk of contracting Hepatitis B) unless they are
directly related to the treatment of an injury or direct exposure to a disease
or condition, such as anti-rabies treatment. In the absence of injury or direct
exposure, preventive immunization (vaccination or inoculation) against diseases
(e.g., shingles) is only covered under the Medicare Part D pharmacy benefit.
Medicare Advantage HMO and PPO members who purchase Part D coverage have the
option to receive preventive Part D vaccines through a participating pharmacy
that accepts Medicare Part D coverage. In addition, there may be instances when
Medicare Advantage HMO and PPO members prefer to have the vaccine supplied and
administered in their physician's office. If the member chooses this option,
the physician will utilize his or her own stock of vaccine and administer it to
the member. Since these vaccines are only covered through the Part D pharmacy
benefit, and not the Medical Part B benefit, the member will have to pay the
physician?s office for the cost of the vaccine and administration out of his or
her own pocket. However, if the member has Part D coverage, he or she can
request reimbursement of his or her out-of-pocket expenses by submitting the
Medicare Part D Vaccine and Administration (Injection) Claim Form, which can be
found at
www.ibxmedicare.com.
For a list of vaccinations covered under Medicare Part B and/or Medicare Part
D, please refer to Claim Payment Policy #08.09.11p: Medicare Part B vs. Part D
Crossover Drugs.