Medicare Part B Coverage for COVID and RSV Vaccines

Medicare Part B Coverage for COVID‑19 Vaccines

Medicare Part B covers COVID‑19 vaccines broadly. Updated 2024–2025 formulations from Moderna, Pfizer‑BioNTech, or Novavax are covered for anyone with Medicare, including those who are older or immunocompromised. 

Patients pay nothing out of pocket for the COVID‑19 vaccine or its administration under Original Medicare, provided the provider accepts assignment. For patients who cannot travel, Part B covers in‑home administration of COVID‑19 vaccines as well.

COVID vaccine billing follows standard preventive vaccine protocols under Medicare Part B vaccine coverage. When billing for these vaccines, providers must use the correct vaccine billing codes and administration codes, apply the ICD‑10 diagnosis code Z23 (encounter for immunization), and if applicable, use modifiers for unique situations like home visits.

Policies for waiver‑related flexibilities during the public health emergency ended in mid‑2023, but the core Part B coverage remains intact.

Medicare vaccine policies expect accurate COVID billing with no patient cost sharing. Pharmacies should become familiar with the current coding for both the vaccine product and administration.

RSV Vaccine Coverage under Medicare

The RSV vaccine is not covered under Medicare Part B. It falls under Medicare Part D drug coverage. Part D plans cover RSV shots at no cost to beneficiaries when they are recommended by the Advisory Committee on Immunization Practices (ACIP), similar to shingles or pertussis vaccines. Patients aged 75 and older or those aged 50–74 with increased risk are encouraged to get the RSV shot.

Because RSV vaccine billing falls under Part D, pharmacies or clinics must submit RSV vaccine billing through the drug benefit rather than medical coverage. They also need to use appropriate pharmacy claim processes and administration fee structures. Long‑term care facility rules emphasize that RSV claims are not subject to consolidated billing under Part A or B.

That means RSV vaccine billing cannot always be handled in the same way as COVID vaccine billing. Pharmacies must differentiate Medicare Part B vaccine coverage for COVID vaccine from RSV vaccine claims under Part D and follow each path precisely to ensure compliance and reimbursement.

Filing a COVID vaccine claim under Medicare Part B ensures patients pay nothing, and your practice gets fairly compensated when you use the right codes and modifiers.

Billing Codes and Administration Fees

Accurate coding is foundational to both COVID vaccine billing and RSV vaccine billing. Immunization coverage under Medicare relies on two parts of the claim: one for the vaccine product and another for administering the injection.

For COVID‑19 vaccines, use:

• The current CMS‑approved HCPCS or CPT vaccine product codes.
• The correct administration code, along with Z23 as the diagnosis code.
• For home administration, include specific codes such as CPT 90480 plus HCPCS M0201 for the in‑home payment modifier.
• If applicable (for hospice or special situations), use the GW modifier to reflect unrelated to the terminal condition.

Medicare pays a set percentage of the average wholesale price for the vaccine product (typically 95 percent of AWP) while administration reimbursement rates may vary by setting or cost report mechanism.

For RSV vaccine billing under Part D:

• Submit the product code under the drug formulary.
• Administration fees may be included or reimbursed separately by the Part D plan provider, depending on whether the administering pharmacy is in‑network.
• LTC pharmacies must bill the Part D plan directly or bill the patient if out‑of‑network; patients can then seek reimbursement.

Pharmacies must include both product and administration codes for every immunization claim. Without both, providers risk denial of payment.

Recognizing that RSV vaccine billing goes through Part D rather than Part B protects your pharmacy from misrouted claims and reimbursement delays.

Ensuring Compliance for Pharmacies

To maintain compliance when billing Medicare Part B for COVID vaccines or managing RSV vaccine billing under Part D, pharmacies should focus on several key considerations.

First, properly enroll in Medicare. Pharmacies must be Medicare Part B enrolled under either the Pharmacy or Mass Immunizer category to bill for COVID‑19 vaccines. A pharmacy PTAN enables individual claim billing, while a Mass Immunizer PTAN supports roster billing for group settings.

Second, document all administration details accurately. Include product and administrative codes, date of service, place of service codes, and any necessary modifiers like home visit or hospice. Use Z23 diagnosis for immunization encounters.

Third, educate staff on policy distinctions. One policy is that COVID vaccine billing belongs under medical benefit Part B, while RSV vaccine claims belong under Part D drug benefit. Staff should avoid mixing these routes to prevent rejected claims.

Fourth, verify patient coverage and benefits—Original Medicare vs. Advantage vs. Part D plan—before administering vaccines. Check whether the RSV benefit is active under Part D for a patient with a specific plan. This avoids claim delays and patient billing confusion.

Fifth, for long‑term care facility settings, follow specific guidance: COVID‑19 vaccine claims (Part B) must be billed separately by the facility, not through consolidated Part A billing. RSV vaccine claims must go through Part D with pharmacy involvement if administered for prevention.

Finally, include vigilance around evolving Medicare vaccine policies. Updates to coding, pricing, or coverage can shift year to year. Maintaining familiarity with CMS vaccine pricing tables and enrollment guidelines safeguards correct COVID vaccine reimbursement and RSV vaccine claims continuity.