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Report: Medicare coverage of adult vaccines is lacking


A new report alleges that commercial plans provide better coverage than Medicare when it comes to vaccinations.

Medicare recipients are paying more out-of-pocket costs than individuals enrolled in commercial plans when it comes to recommended vaccinations for adults, according to a new report.

The Avalere Health report reveals that only 12% of Medicare Advantage enrollees-which make up 4% of all Medicare Part D participants-had access to a set of 10 recommended vaccinations without having to pay out-of-pocket expenses in 2016. None of the standalone Medicare Part D plans fully cover vaccinations for tetanus, Hepatitis A, of Hepatitis B, according to the report.

“Rates of vaccine-preventable illnesses are particularly high among older adults,” Caroline Pearson, senior vice president at Avalere, tells Medical Economics. “While most private insurance plans are now required to cover recommended vaccines at no cost to the patient, very few Medicare beneficiaries enjoy this same level of coverage.”

Increased immunization rates are a goal under Healthy People 2020, the Centers for Disease Control and Prevention (CDC) offers recommendations on 17 vaccine-preventable diseases, and the Affordable Care Act (ACA) requires most commercial health plans to fully cover vaccinations at no additional cost to patients, the report notes.


The 10 vaccinations reviewed by Avalere were those that had age-specific recommendations for seniors or that protected against diseases or conditions for which seniors are at high risk. They include: Boostrix (Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine, Adsorbed), Zostavax (Zoster Vaccine Live), Varivax (Varicella Virus Vaccine Live), Menomune (Meningococcal Polysaccharide Vaccine, Groups A, C, Y, W135 Combined), Havrix  (Hepatitis A Vaccine), VAQTA (Hepatitis A Vaccine, Inactivated), Energix-B [Hepatitis B Vaccine (Recombinant)], RECOMBIVAX-HB [Hepatitis B Vaccine (Recombinant)], Twinrix [Hepatitis A Inactivated & Hepatitis B (Recombinant) Vaccine], and Tenivac (Tetanus and Diphtheria Toxoids, Adsorbed).

According to Avalere, about 80% to 90% of Medicare Part D enrollees paid a fixed dollar amount for those vaccines in 2015 compared to between 47% and 72% in standalone prescription drug programs that paid a fixed dollar amount, for the vaccines.

“The key benefit of expanding coverage for adult vaccines is to improve the health of Medicare beneficiaries and avoid preventable illnesses,” says Pearson. “Broader use of adult vaccines could reduce the incidence of these diseases. Our report provides information about the current coverage landscape for adult vaccines in the Medicare program. It also calls attention to the discrepancy in coverage between Medicare, which regularly charges patient cost-sharing for these vaccines, compared to other sources of insurance where such vaccines are provided for free.”

While there is not much primary care physicians can do to impact vaccine coverage by the Medicare program, they can work to raise awareness about adult vaccines and the importance of compliance with the recommended vaccine schedule, she says.


Pearson admits that expanded coverage of adult vaccines by Medicare would increase healthcare costs, particularly in the form of higher costs for the government and higher premiums in Medicare Part D, but she reasons that those higher costs will be offset by a decrease in spending to treat the preventable diseases the vaccines could help eliminate.

GlaxoSmithKline funded the Avalere’s analysis.










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