Medicare coverage of Zostavax

[participant1]

Is Zostavax covered under Med D and do health plans must cover it for Med D recipients?

[diana.papshev]

The short answer is yes.

Preventative vaccines such as Zostavax are considered to be Part D products (exceptions include Hep B, influenza, and pneumococcal vacines) and must be covered under the Part D benefit. Starting January 1, 2008, administration of these vaccines is also included in the definition of “covered Part D drug” under the Part D statute. The CMS specifies that "Part D sponsors may implement drug utilization management tools to determine if a vaccine is necessary; however, in the absence of any information showing previous immunization (i.e., claims data), the Part D plan should make payment available for a vaccine and its administration in consideration with ACIP recommendations."

Of note, even if Zostavax is administered during a Part A stay in a SNF, it should still be covered under the Part D benefit since it's outside the scope of the Part A benefit.

Sources:

CMS. Medicare Learning Matters; January 2007.

CMS. Vaccine Administration; May 2007.

Visiting Nurse Associations of America. CMS Letter on Part D Coverage of Preventive Vaccines Provided to Medicare
Beneficiaries in Skilled Nursing Facilities During a Medicare-Covered Stay (Distributed by Merck); November 2007.

[chantell.reagan]

As administration of vaccines through the Medicare benefit can be complicated, please see one plan's approach to the their coverage:
http://www.aetna.com/members/medicar...erageChart.pdf