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 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/