If your doctor recommends a vaccine for something other than flu, pneumonia or hepatitis B (which are all vaccines covered under Part B), the vaccine should be paid for by your Part D plan. All Part D plans must include all commercially available vaccines on their formularies, including the vaccine for shingles (herpes zoster).
However, the amount you pay for your vaccination could vary based on where you get vaccinated. Before you get a vaccination, you should check coverage rules with your Part D plan and see where you should get your shot so that it will be covered for you at the lowest cost.
- You will pay the least for your vaccination if you are vaccinated at:
- pharmacy that is in your drug plan’s network (an in-network pharmacy) if this is permitted in your state; or
- a doctor’s office that
- can work with a pharmacy that will bill your Part D plan for the entire cost of the vaccination process (the drug and its injection); or
- can bill your plan for the vaccination process directly using a special computer billing system.
In the above circumstances, you will end up paying the least for your vaccination and should only need to pay the plan’s approved coinsurance or copay for the drug and vaccination either to the doctor or to the pharmacist when you get vaccinated.
When you are at your doctor’s office, ask your doctor to call your Part D plan first to find out if there is a way that she can bill your plan for the vaccination. There may be a way for her to submit the bill so that you will not have to pay the whole cost up front.
- You may need to pay more for your vaccination if your doctor
- cannot submit the bill to your Part D plan through a partnering pharmacy; and/or
- does not directly bill your plan for the drug using the electronic billing system.
In these circumstances, the doctor will bill you for the entire cost of the vaccination (the drug and its injection) and you will have to pay the entire bill up front. You will then have follow your Part D plan’s rules to get a refund (reimbursement). The doctor is not limited in how much she can charge you for the vaccine but your Part D plan will only pay its approved amount for the vaccine costs. When you are reimbursed by the plan, you will only be reimbursed for your Part D plan’s approved payment. You will be responsible for the difference between the doctor’s charge and the plan’s approved payment.
If you have Extra Help, you can go to any doctor or in-network pharmacy. You will be covered for your vaccination and will only be responsible for the Extra Help copay. However, you may need to pay the entire bill up front and then be reimbursed by your Part D plan if you get vaccinated by a provider who does not directly bill your Part D plan.