Immunizations under Medicare Parts B & D

Medicare reimbursement

• Vaccine administration services are not reimbursed when the vaccine is covered under the Medicare Part D program.
• Hepatitis A, rabies and tetanus vaccines and their administration are covered under the Part B program when a provider meets specific Medicare criteria and reports an appropriate diagnosis.
• Hepatitis B, influenza and pneumococcal vaccines and their administration are covered when the provider reports the appropriate G code (below) for administration of these vaccines. If you bill a 90471 or 90472, these services may deny as non-covered.
• 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. "MLN Matters" articles MM5443 and M5459 specifically address these issues.

Open the CMS Tip Sheet: Medicare Drug Coverage Under Medicare Part A, Part B, and Part D.

Immunizations covered under Part B (Medical Benefit) vs. Part D

PriorityMedicare^SM follows the immunization coverage guidelines found under Local Coverage Determination L16973.  The following immunizations are covered according to Medicare requirements – i.e., immunizations, vaccinations or inoculations are covered only when there has been direct exposure of the associated disease to the patient and that there is significant risk that the patient could contract the disease as a result of the exposure.

 

Part B: 
The following immunizations are covered by law and Medicare guidelines for coverage, and are always a Part B benefit :

• Pneumococcal pneumonia (PPV)
• Hepatitis B (see under Hepatitis B for more information)
• Influenza

The following are covered under Part B Medicare only if directly related to treatment of an injury or direct exposure. Otherwise these are covered under Part D, subject to formulary requirements:

• Anti-rabies
• Anti-venin
• Botulin antitoxin
• Diphtheria
• Immune globulin
• Tetanus antitoxin or booster vaccine
• Tetanus and diphtheria for people incompletely immunized

Part D:
When an immunization is not covered under Part B, it is always covered under Part D. However, Part D immunizations:

• Are subject to the rules of the PriorityMedicare formulary
• May require prior authorization before administration

Immunizations may be obtained either through a Vaccine Network pharmacy (not possible in all states) or in a physician's office.

aDMINISTERED at:	administered by:	Member pays (and/or is reimbursed):
Pharmacy	Pharmacy (not possible in all states)	Normal coinsurance or copay for the vaccine
Doctor's office	Doctor	Member pays for entire cost of vaccine and administration up-front Member submits claim for reimbursement through plan Member is reimbursed amount less: 1. Normal copay or coinsurance for vaccine and 2. Any difference between the amount the physician charges and what Priority Health normally pays*
Pharmacy	Doctor	Member pays normal copay or coinsurance for vaccine at pharmacy Member pays full amount charged by the doctor for administering the vaccine Member submits claim for reimbursement of physician charges to plan Member is reimbursed the amount charged by the doctor less: 1. Normal copay or coinsurance for vaccine and 2. Any difference between the amount the doctor charges and what Priority Health normally pays*

*If member receives extra help from Medicare, Priority Health will reimburse the provider for the difference.