The Zostavax ® vaccine for prevention of shingles (herpes zoster) is excluded from Part B Medicare coverage. Medicare manual instructions [ Medicare Benefits Manual (Pub. 100-02), Chapter 15, Section 50.4.4.2 – Immunizations ] (see below) prohibit such coverage unless the beneficiary is at risk directly related to exposure to a pathogen. In the absence of an immunocompromised state, beneficiaries are not at direct risk for developing herpes zoster. In an immunocompromised state, the vaccine is contraindicated and should not be administered. Therefore, neither the vaccine nor its administration can be covered by Part B Medicare. However, the vaccine (but not the administration) is covered under the Part D Medicare benefit. The administration fee is a beneficiary responsibility.

Medicare Benefits Manual (Pub. 100-02), Chapter 15 50.4.4.2 – Immunizations (Rev. 1, 10-01-03) A3-3157.A, B3-2049.4, HO-230.4.C
Vaccinations or inoculations are excluded as immunizations unless they are directly related to the treatment of an injury or direct exposure to a disease or condition, such as anti-rabies treatment, tetanus antitoxin or booster vaccine, botulin antitoxin, antivenin sera, or immune globulin. In the absence of injury or direct exposure, preventive immunization (vaccination or inoculation) against such diseases as smallpox, polio, diphtheria, etc., is not covered. However, pneumococcal, hepatitis B, and influenza virus vaccines are exceptions to this rule...In cases where a vaccination or inoculation is excluded from coverage, related charges are also not covered.

Posted: 11/28/2006

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