Has Anyone Heard This Before? Humana Medicare and Tetanus Vaccine

[lancefinley]

My wife was talking with a Humana Medicare Customer Service Rep regarding coverage for a tetanus shot.  She was told that she has two options: 1) Have a covered pharmacy administer the shot (which make sense), or 2) if she wanted her physician to administer it she would have to purchase the vaccine from a covered pharmacy, take it to the physician and have them administer it (which makes absolutely no sense).  Has anyone else encountered this?  Right now, I am assuming the Customer Service Rep doesn't know what they are talking about, but then again, we are new to Medicare.  Thanks for any help on this.

[GailL1 · Accepted solution]

There is a [logical] reason for this and presently it covers several vaccines that are covered under Medicare Part D rather than Medicare Part B.

The explanation is that the doctor although covered by Medicare (Part B)  CANNOT bill a Prescription Drug plan (Part D)  if that is where the medication is covered; at least if it is needed for as a preventive measure - only drug distribution facilities like pharmacies can bill Part D prescription Drug plans (Part D)  when it is needed as a preventive measure.

Medicare.gov Tdap shots

from the link ~

Medicare prescription drug coverage (Part D) usually covers all commercially available vaccines needed to prevent illness, including the Tdap shot.

Medicare.gov Part B Outpatient Prescription Drug Coverage

from the link:

• Shots (vaccinations): Medicare covers flu shots, pneumococcal shots, Hepatitis B shots, and some other vaccines when they’re related directly to the treatment of an injury or illness.

Now let's say that you need a tetanus shot after some injury rather than as a preventive measure - then it would be covered under Part B anywhere you might get it - doctor office, urgent care, ER.

If this is for tdap, as a preventive measure - just get it at the pharmacy.  

However, the recently signed into law IRA (Inflation Reduction Act) will also have some impact here because in 2023 - The IRA will expand adult vaccine access by mandating coverage without cost sharing for all adult vaccines in Medicare Part D and Medicaid.

Alavere 08/16/2022 - The IRA will expand adult vaccine access by mandating coverage without cost sha...

Medicare is really a very complicated system - isn't it !?!

[lancefinley]

Thanks so much for your explanation.  As you note, it is best to get the shot from the pharmacy as she is getting it as a preventive measure.  Our local pharmacy confirmed they have the vaccine so we'll be making an appointment with them shortly.  Again, thank you for explaining this!