Immunizations under Medicare Parts B & D
Coverage for routine preventive immunizations
Medicare Part B, the medical benefit, always covers 3 routine immunizations:
In addition, Part B may from time to time cover preventive immunizations for diseases endemic in the U.S.
Medicare Part D, the prescription drug benefit, covers all other routine preventive immunizations, except for those to prevent the diseases endemic to the U.S. mentioned above.
Members can get routine Part D vaccinations at a Vaccine Network pharmacy. Vaccine Network Pharmacies are indicated by a "V" before their name in the Pharmacy Directory. Go to Medicare member pharmacy information.
Exceptions for immunization after exposure to disease
Priority Health Medicare follows Medicare guidelines found under WPS-Medicare Local Coverage Determination (LCD) L34596 at www.wpsmedicare.com. According to L34596, the immunizations listed below are covered by Medicare Part B when:
- There has been direct exposure of the associated disease to the patient, and
- There is significant risk that the patient could contract the disease as a result of the exposure.
Coverage applies ONLY to:
- Diptheria, antitoxin (CPT code 90296)
- Hepatitis A (CPT codes 90632, 90633, 90634)
- Immune globulin subject to the requirements of L30147, Immune Globulins
- Rabies prophylaxis (CPT codes 90675, 90676)
- Tetanus and diphtheria toxoids (CPT codes 90702, 90714, 90715)
For any other codes, you must follow the pre-service organization determination process to obtain a notice of non-coverage and/or approval for the immunization. If we deny the request and provide you and the member with a notice of the denial, you may then bill with the GA modifier to show that notice was given. Learn more about Notices of Non-Coverage.
See also Billing for vaccines in this Manual.
Reimbursement for covered Part B immunizations
When submitting claims for covered Part B vaccines or immunizations, follow L34596 billing rules.
Billing for administration under Part B
Do NOT use 90471 or 90472 when billing for the administration. These services will deny as not covered and go to provider liability.
Use these Medicare-specific HCPCS codes for administration:
- G0008 – Administration of influenza virus vaccine
- G0009 – Administration of pneumococcal vaccine
- G0010 – Administration of Hepatitis B vaccine
- G9141 – Administration of Influenza A (H1N1) vaccine
Additional information is available at the CMS website.
Review the CMS Tip Sheet: Medicare Drug Coverage Under Medicare Part A, Part B, and Part D.
Reimbursement for covered Part D immunizations
A member can get these immunizations at a Vaccine Network pharmacy for his or her Part D prescription drug benefit copay. At a physician office, the member owes 100% of the cost of the vaccine and administration.
Vaccine administration services are not reimbursed under the Medicare Part D program.
If a member asks a physician/physician office to provide a Part D Medicare-covered immunization:
- Let the member know that the immunization is not covered under Part B but is covered under Part D.
- You may want to let the member know that he/she can go to a Vaccine Network pharmacy, where the out-of-pocket expense will be the member's Part D cost share.
- If the member still chooses to receive the vaccination in your office, you should advise that he/she will be 100% responsible for the cost of the vaccine and its administration. You may collect the cost of the vaccine plus administration fee at time of service or bill the member later. However you still must bill us for the service.
- Submit a claim with the GY modifier to show the service is excluded under the member's medical benefit. This claim will deny as member liability allowing you to bill the member if you have not collected the money at time of service. Your claim will also allow us to coordinate with Part D. We will issue an Explanation of Benefits (EOB) to the member explaining that the vaccine or drug is covered under Part D. We will then coordinate submission of the claim to our pharmacy benefits manager (PBM).
- Our PBM will pay the member for the cost of the vaccine only after it takes out the member's cost-share.