Take Advantage of Medicare Vaccine Coverage

What Vaccines Are Available and Are They Right For You?

People tend to think of children when they think about vaccination. There is no question that certain vaccines are tailored to younger populations,  such as those for the measles, mumps, polio, rubella and even human papillomavirus (HPV). However, vaccines are not only for the young. They can be used to prevent disease as we get older too.

Medicare recognizes this and covers vaccines in adulthood. It is important for you to know what vaccines are available to you, and why you may need them.

1
Medicare Coverage for the Flu Shot

Nurse giving older man a vaccine
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Influenza, aka the flu, is a viral infection that sickens tens of thousands of people across the world every year and sometimes more. Fever, chills, headache, cough, sore throat and muscle aches are hallmark signs of the disease though there is a wide spectrum of symptoms. Complications can vary from ear infections to pneumonia and, in the most severe cases, death. In 2013, the Centers for Disease Control and Prevention (CDC) reported 3,697 deaths in the United States from the flu.

The Advisory Committee on Immunization Practices recommends that anyone over six months of age be vaccinated against influenza. It is especially encouraged for people with asthma, diabetes, heart disease or anyone with a weakened immune system. Conditions like cancer and HIV fall into this category.

Accordingly, Medicare covers flu vaccination once every fall-winter season under its Part B benefit. The benefit will not cost you anything if your doctor has signed an agreement with Medicare.

The vaccine can be administered either as a shot or as a nasal spray, as an inactivated virus or a live virus respectively. The CDC recently reported that the nasal-spray version of the vaccine has not been proven adequately effective against influenza. As a result, it will no longer be recommended as of June 2016. 

In some cases, a high-dose flu vaccine may be available to offer increased protection to the elderly. Medicare covers this vaccine as well. You can discuss the different options with your healthcare provider and decide which vaccine works best for your situation.

2
Medicare Coverage for the Pneumonia Shot

woman receives vaccine from her doctor
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Pneumonia is a lung infection that can be caused by bacteria, viruses, and even fungi. Symptoms may include fever, cough, shortness of breath, and low oxygen levels in the body. According to the Centers for Disease Control and Prevention, there were more than 1.1 million hospital stays for pneumonia in 2010 with the average stay lasting over five days. Of these hospital stays, there were three deaths for every 100 people.

It once was the case that getting a single pneumonia shot after 65 years old was enough to keep the most aggressive types of pneumonia at bay. Recommendations have since changed so that two different kinds of vaccinations are now recommended, PCV13 and PPSV23. Each vaccine targets different serotypes of pneumococcal pneumonia and together they optimize protection against the bacteria. Vaccinations have not been developed against the other causes of pneumonia.

Your Medicare Part B benefit covers both pneumococcal vaccines after age 65. The PCV13 is given first with the PPSV23 recommended six to 12 months after. The vaccine is free if your healthcare provider agrees to Medicare's Physician Fee Schedule. Keep in mind, however, that Medicare only pays for one dose of each vaccine. Any additional pneumonia shots, even at the recommendation of your doctor, will come at an additional cost. This is the case even if you are a patient with an underlying lung condition that puts you at higher risk for pneumonia.

3
Medicare Coverage for the Hepatitis B Shot

woman with abdominal pain and hepatitis b
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Hepatitis B is a virus that attacks the liver. Exposure to hepatitis B occurs when you come in direct contact with the blood or other bodily fluids of an infected person. It is not enough, however, to simply touch the fluid to be infected. The fluid must enter your body as well. For example, the virus can be transmitted through blood transfusions, open wounds, sexual intercourse, and vaginal birth.

Hepatitis B can cause acute liver disease, cirrhosis, and even liver cancer (hepatocellular carcinoma). More than five percent of Americans have been infected with hepatitis B. The majority of people will clear the disease from their body while others live symptom-free with the disease on a chronic basis. Some people who have chronic hepatitis B will develop complications over time.

Medicare Part B does not cover Hepatitis B vaccination for everyone. It only covers it for those considered to be at risk for the disease. Examples of conditions that may increase your risk for hepatitis B include:

Health care workers, people in prisons and those who live in institutionalized facilities or group homes are also considered to be at higher risk for hepatitis B.

If your doctor agrees to terms set by Medicare, the hepatitis B vaccine series will be free to you under the Part B benefit. Talk with your healthcare provider to find out if you are a candidate for the three-shot series.

4
Medicare Coverage for the Shingles Shot

man with shingles pain
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Once you have chicken pox, the virus that causes it lives in your body forever. If you are one of the lucky ones, it will never bother you again. The fact remains that for one in three people the virus gets reactivated in the body. This typically occurs during times of stress or illness and can happen whether you are young or old. The painful, burning, or itchy rash that develops on one side of your body is known as shingles.

Shingles, as uncomfortable as it can be, is often a self-limiting illness. However, a long-lasting pain syndrome known as post-herpetic neuralgia can develop. This complication can be debilitating in some cases and can decrease your quality of life. Beware that you can develop shingles more than once in your lifetime.

The vaccination for shingles has been shown to decrease outbreaks of the disease as well as the risk for postherpetic neuralgia when shingles occurs. Certain Medicare Advantage plans or Part D plans may cover the one-time administration of this vaccine. Unfortunately, it is usually not free and may require a copayment. Actual costs will vary based on your plan's drug formulary.

5
Medicare Coverage for the Tetanus (and Pertussis) Shot

tetanus pertussis vaccine
Medicare may cover tetanus vaccination after an injury. PM Images / DigitalVision / Getty Images

Tetanus, also referred to as lockjaw, is an infection caused by the bacteria Clostridium tetani. It is not a common disease in the United States but it affects as many as one in ten people worldwide. When the bacteria gets under your skin and into deep tissues, it causes muscle spasms and can even affect the muscles that control your breathing. In severe cases, it can be life threatening.

The good news is that the disease is preventable with vaccination. A series of tetanus shots is recommended in childhood, and adults are encouraged to get boosters every 10 years.

Medicare Part B pays 100 percent of the cost for tetanus vaccination in specific cases. People with diabetes and/or neuropathy, for example, may not have good sensation on their feet and could have an open sore on the skin that increases their risk for tetanus. Other people may have injuries that lead to puncture wounds, for example, animal bites or stepping on a nail.

If you want to get the tetanus booster and have not had an illness or trauma, you will need to turn to your Medicare Advantage plan or Part D plan for coverage. There will likely be a charge for the vaccine depending on your plan's medication formulary.

Another consideration is protection against pertussis, aka whooping cough. Pertussis can be dangerous and even life-threatening for young children and those with weak immune systems. Vaccination against pertussis is only available when combined with the tetanus vaccine.

The Tdap (tetanus, diphtheria, and pertussis) shot is not covered under the Part B benefit and may or may not be covered by your Medicare Advantage plan or Part D plan. Please check with your plan's formulary.

It is recommended that you get at least one Tdap booster as an adult and consider additional vaccination to prevent spreading pertussis to at-risk individuals with whom you have close contact. All pregnant women are advised to get Tdap vaccination in the third trimester or immediately after delivery to protect their newborns.

Sources:

Centers for Disease Control and Prevention. Shingles Surveillance. http://www.cdc.gov/shingles/surveillance.html. Updated May 1, 2014. Accessed May 16, 2016.

Centers for Medicare and Medicaid Services. Payment for Part D Vaccines under the Medicare Drug Benefit (Part D). https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0678.pdf. Accessed May 15, 2016.

Hepatitis B Foundation. Statistics. http://www.hepb.org/hepb/statistics.htm. Updated January 15, 2016. Accessed May 16, 2016.

National Center for Health Statistics. FastFacts: Influenza. http://www.cdc.gov/nchs/fastats/flu.htm. Updated April 27, 2016. Accessed May 16, 2016.

National Center for Health Statistics. FastFacts: Pneumonia. http://www.cdc.gov/nchs/fastats/pneumonia.htm. Updated October 7, 2015. Accessed May 16, 2016.

Deciding Which Vaccines Are Right for You

No one has time to get sick. If you have Medicare, it may be in your best interest to protect yourself against diseases and consider these common vaccinations. However, there can sometimes be contraindications to using certain vaccines. Talk with your healthcare provider about which options may be best for you.

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