Insurance Coverage for Vaccines

Are there any out-of-pocket costs for members that receive a COVID-19 vaccine? 

No. Expert members in Commercial and Medicaid plans will not have to pay any out-of-pocket costs for a COVID-19 vaccine. For Medicare beneficiaries, CMS will cover the full cost of the vaccine, including those in a Medicare Advantage plan.

Are there any out-of-pocket costs for members who go to an in-or out-of-network pharmacy or provider for their vaccine? (As of 8/27/2021)

No. Expert members in Commercial and Medicaid plans will not have to pay any out-of-pocket costs for a COVID-19 vaccine, regardless of whether they go to an in-or out-of-network pharmacy or provider.

CMS pays for the cost of the vaccine for all Medicare beneficiaries. This includes, those in a Medicare Advantage plan, regardless of whether they go to an in-network or out-of-network pharmacy or provider. Please be sure to bring and show your red/white/blue Medicare ID card or your Medicare Number – not your Expert member ID card – when you get vaccinated. This will help your health care provider or pharmacy to bill Medicare.

Will Expert plans cover the cost of administering a third dose of an mRNA vaccine for immunocompromised members? (As of 8/27/2021)

Yes. Since a third dose of the Pfizer-BioNTech and Moderna vaccines is recommended by the FDA and authorized by the CDC for individuals with weakened immune systems, the administration of a third mRNA COVID-19 vaccine is covered for those Expert plan members.

For Medicare beneficiaries, including those in a Medicare Advantage plan, CMS will cover the cost for the third vaccine dose for those who qualify.