Medicare Part B Vaccine Coverage

Medicare Part B provides preventive coverage only for certain vaccines. These include:

Administration services for these preventive vaccines are reported to Medicare using HCPCS codes as follows:

The diagnosis codes to report with these preventive vaccines are:

Complete information on these preventive vaccines (including indications of high risk and coverage of re-vaccination) can be found in the Centers for Medicare and Medicaid Services' Guide to Medicare Preventive Services (298-page PDF; About PDFs). A quick reference guide to Part B preventive services (2-page PDF; About PDFs) is also a useful resource for verifying which patients have benefits for the preventive vaccines, codes to use, frequency of coverage and patient out-of-pocket expenses.

Other immunizations are covered under Medicare Part B only if they are directly related to the treatment of an injury or direct exposure, such as antirabies treatment, tetanus antitoxin or booster vaccine, botulin antitoxin, antivenin or immune globulin.

Coverage of other vaccines provided as a preventive service may be covered under a patient's Part D coverage.

Whether participating or non-participating in Medicare, physicians must accept assignment of the Medicare vaccine payment rate and may not collect payment from the beneficiary for the vaccine. Non-participating physicians may choose not to accept assignment on the administration fee. When a non-participating physician or supplier provides the services, the beneficiary is responsible for paying the difference between what the physician or supplier charges and the amount Medicare allows for the administration fee. The limiting charge provision does not apply to the influenza benefit.

The influenza and pneumococcal vaccines and the administration of these vaccines are not subject to the Medicare Part B deductible or co-insurance. Medicare pays at 100% of the allowable amounts. However, the Hepatitis B vaccine and administration are subject to the deductible and co-insurance. Medicare pays at 80% after the patient has met their Part B deductible.

Medicare will pay two administration fees if a beneficiary receives both the influenza virus and the pneumococcal vaccine on the same day.

Claims for the hepatitis B vaccine must include the name and NPI of the ordering physician, as Medicare requires that the hepatitis B vaccine be administered under a physician’s order with supervision. This is not necessary for the influenza and pneumococcal vaccines for which Medicare does not require a physician's order or supervision. (Note that state law may require an order and/or supervision.)

You can find the allowable amounts for the influenza, pneumococcal and hepatitis B vaccines and their administration on your Medicare Part B contractor's web site or the Centers for Medicare and Medicaid Services' (CMS) web site.

The influenza vaccine allowables are posted by CMS each year. The allowables for the pneumococcal and hepatitis B vaccines are included in the average sale price files listed on the CMS site as ASP Drug Pricing Files. These files are updated quarterly by CMS and often show retroactive updates to pricing information. When there is an increase in your costs for a vaccine that is put in place prior to the CMS updates to their pricing files, it may be worthwhile to request an adjustment to previously paid claims.

The Medicare allowable for the vaccine administration codes will be the same as the amount allowed for CPT code 90471, which is the code for immunization administration provided to adults or provided to children without physician counseling (e.g., doses of childhood vaccine series subsequent to the first dose).