Vaccine Coverage

Some vaccines are considered medical benefits and are covered under Part B. Other vaccines are considered Part D drugs. You can find these vaccines listed in the SummaCare Medicare Formulary. Our plan covers most adult Part D vaccines at no cost to you even if you haven’t paid your deductible. Refer to the SummaCare Medicare Formulary or contact SummaCare Medicare Member Services for coverage and cost-sharing details about specific vaccines.

Part D Coverage of Vaccines

A few examples of Part D covered vaccines include Shingrix (Shingles) vaccine, RSV vaccine, Tetanus vaccine, and MMR (measles, mumps, rubella) vaccine.

There are two parts to our coverage of Part D vaccinations:

• The first part of coverage is the cost of the vaccine itself.
• The second part of coverage is for the cost of giving you the vaccine. (This is sometimes called the administration of the vaccine.)

Your costs for a Part D vaccination depend on three things:

1. Whether the vaccine is recommended for adults by an organization called the Advisory Committee on Immunization Practices (ACIP).
   • Most adult Part D vaccinations are recommended by ACIP and cost you nothing.
2. Where you get the vaccine.
   • The vaccine itself may be dispensed by a pharmacy or provided by the doctor’s office.
3. Who gives you the vaccine.
   • A pharmacist or another provider may give the vaccine in the pharmacy. Alternatively, a provider may give it in the doctor’s office.

Where should I get my preventive Part D vaccines?

What you pay at the time you get the Part D vaccination can vary depending on the circumstances and what drug payment stage you are in.

• Sometimes when you get a vaccination, you have to pay for the entire cost for both the vaccine itself and the cost for the provider to give you the vaccine. You can ask our plan to pay you back for our share of the cost. For most adult Part D vaccines, this means you will be reimbursed the entire cost you paid.
• Other times, when you get a vaccination, you will pay only your share of the cost under your Part D benefit. For most adult Part D vaccines, you will pay nothing.

Below are three examples of ways you might get a Part D vaccine.

Situation 1: You get the Part D vaccination at the network pharmacy.

(Whether you have this choice depends on where you live. Some states do not allow pharmacies to give certain vaccines.)

• For most adult Part D vaccines, you will pay nothing.
• For other Part D vaccines, you will pay the pharmacy your copayment for the vaccine itself which includes the cost of giving you the vaccine.
• Our plan will pay the remainder of the costs.

Situation 2: You get the Part D vaccination at your doctor’s office.

• When you get the vaccine, you may have to pay for the entire cost of the vaccine itself and the cost for the provider to give it to you.
• You can then ask our plan to pay our share of the cost by submitting a reimbursement request.
• For most adult Part D vaccines, you will be reimbursed the full amount you paid. For other Part D vaccines, you will be reimbursed the amount you paid less any copayment for the vaccine (including administration), and less any difference between the amount the doctor charges and what we normally pay. (If you get “Extra Help,” we will reimburse you for this difference.)

Situation 3: You buy the Part D vaccine itself at the network pharmacy, and then take it to your doctor’s office where they give you the vaccine.

• For most adult Part D vaccines, you will pay nothing for the vaccine itself.
• For other Part D vaccines, you will pay the pharmacy your copayment for the vaccine itself.
• When your doctor gives you the vaccine, you may have to pay the entire cost for this service.
• You can then ask our plan to pay our share of the cost by submitting a reimbursement request.
• For most adult Part D vaccines, you will be reimbursed the full amount you paid. For other Part D vaccines, you will be reimbursed the amount you paid less any coinsurance for the vaccine administration, and less any difference between the amount the doctor charges and what we normally pay. (If you get “Extra Help,” we will reimburse you for this difference.)

*If you get the Part D vaccine at your doctor’s office and they are signed up with Transact Rx Vaccine Manager, and the vaccine is not identified as an adult ACIP-recommended vaccine, you will have to pay the doctor’s office the applicable copayment for the vaccine and the cost of giving you the vaccine. Our plan will pay the remainder of the cost.

Part B Covered Vaccines (Covered under your Medical benefit)

Medicare Part B covers the following vaccines:

• Influenza (flu) virus vaccine;
• COVID-19 vaccine;
• Pneumococcal (pneumonia) vaccine;
• Hepatitis B vaccine (if you are at medium to high risk per your physician); and
• Vaccines directly related to the treatment of an injury or direct exposure to a disease or condition.

Where should I get my Part B vaccines?

You can obtain these vaccines through your network physician. You can also get your flu shot at one of our network pharmacies.