Immunizations under Medicare Parts B & D
Routine preventive immunizations coverage
Medicare Part B, the medical benefit, always covers 4 routine immunizations:
- Pneumococcal pneumonia (PPV): Two doses, each different, 11 full months apart, for those who have never received the vaccine under Medicare Part B
- Influenza: See coding information for vaccines and administration
- Hepatitis B: When the member is at intermediate or high risk for contracting Hepatitis B. See the Medicare Managed Care Manual, Chapter 15, Section 22.214.171.124 B for detail on individuals considered high risk.
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. The member's Part D cost sharing will also apply.
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.
Immunization after exposure to disease or injury
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.
Covered Part B immunizations billing
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.
Covered Part D immunizations billing
Payable: When a member goes to a Vaccine Network pharmacy and pays the Part D prescription drug benefit copay.
- When administered at a physician office or outpatient clinic. 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 also 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, 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. No pre-service organization determination or Notice of Non-coverage is needed.
- You still must bill us for the service. Submit the 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). The Priority Health Pharmacy department does not automatically coordinate the processing of a denied part B facets claim for a part D vaccine. The member must submit a Member Reimbursement Form for reimbursement.
- Our PBM will pay the member for the cost of the vaccine only after it takes out the member's cost-share.