Vaccine Coverage

This is a newsletter article. The information may not be up-to-date. If you have questions, please contact your Provider Coordinator.

Location of Service Matters

Vaccine coverage can vary depending on your patient’s specific insurance plan. The most important factor is whether a patient is covered by a commercial insurance plan or a Medicare plan.

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