Medicare Coverage of Vaccinations
What It Is
Vaccinations to help prevent specific diseases
Medicare Part B covers these vaccinations, provided in any setting, under the following conditions:
Flu. Flu shot, one per flu season (usually in fall or winter). Note that the seasonal flu shot now includes protection against H1N1.
Pneumonia. Pneumococcal shot, to help prevent certain types of pneumonia. Most people only need one such vaccination in a lifetime.
Hepatitis B. Hepatitis B shot, for people at high or medium risk for the disease.
Medicare Part B doesn't cover vaccinations for other diseases.
If you have a Medicare Part C Medicare Advantage plan: Medicare Part C, also called a Medicare Advantage plan, covers everything that's included in original Medicare Part A and Part B, and sometimes more. Check directly with your plan to find out if it covers vaccinations in addition to the three covered by Medicare Part B.
If you have a Medicare Part D prescription drug plan: All Medicare Part D prescription drug plans must cover any commercially available vaccination (other than the three vaccinations already covered by Part B, described above), if prescribed by your physician.
What Medicare Pays
For flu and pneumonia shots, Medicare Part B pays 100 percent of the Medicare-approved amount.
For a hepatitis B shot provided in a doctor's office, Medicare Part B pays 80 percent of the Medicare-approved amount. For a hepatitis B shot provided in a hospital outpatient department, Medicare Part B pays the entire Medicare-approved amount, except for a patient co-payment.
Medicare Part B pays nothing for any vaccination other than for flu, pneumonia, or hepatitis B.
If your Medicare Part C Medicare Advantage plan covers vaccinations other than the three covered by Medicare Part B, check with your plan directly to find out if there are any co-payments.
If you have a Medicare Part D prescription drug plan, check with the plan directly about co-payments for vaccinations other than the three covered by Medicare Part B.
Important: Regardless of the rules regarding any particular type of care, in order for Medicare Part A, Medicare Part B, or a Medicare Part C plan to provide coverage, the care must meet two basic requirements:
The care must be "medically necessary." This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or a Medicare Part C plan) agrees that the care is necessary and proper. For help getting your care covered, see FAQ: How Can I Increase the Odds That Medicare Will Cover My Medical Service?
The care must be performed or delivered by a healthcare provider who participates in Medicare.
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