Vaccine Coverage

Quartz Commercial Vaccine Coverage

Generally, vaccines are available at no cost to members. Coverage is different depending on the location where the vaccine was given.

• All vaccines are covered when given by an in-network provider at a clinic, etc.
• Vaccines are not covered at the pharmacy, with one notable exception – the Influenza vaccine is covered both at a provider’s office and at a pharmacy.

Some vaccines have age restrictions. Please consult the Medication Prior Authorization Criteria for details before administration.

Medicare Coverage

Medicare Part B (administered in a clinic or retail pharmacy setting) covers –

• Influenza virus vaccine
• Pneumococcal pneumonia vaccine
• Hepatitis B vaccine (for patients at high or intermediate risk)
• Vaccines directly related to the treatment of an injury or direct exposure to a disease or condition (i.e. a tetanus immunization if patient has stepped on a rusty nail, rabies immunization if bitten by a dog, etc.)

Medicare Part D (administered in a retail pharmacy) covers –

• All other vaccines not listed above.

Medicare Part D-covered vaccines should generally be administered at a pharmacy. Pharmacies are set up to easily bill Medicare Part D.

Most medical providers are not set up to bill Medicare Part D. If providers administer the vaccine in a clinic or other provider facility, the patient will typically be faced with a higher bill than if had they received the same vaccine at a pharmacy.

For more information, see the Medicare Part D Vaccines and Vaccine Administration Fact Sheet at cms.gov/Medicare/Prevention/
PrevntionGenInfo/ProviderResources.html