CDPHP® Medicare Advantage Vaccine Coverage Guide Part B (Medical) vs. Part D (Pharmacy)

Medicare Part B (Medical): Medicare Part D (Pharmacy): Vaccinations or inoculations Vaccinations or inoculations are included when the administration is (except influenza, pneumococcal, reasonable and necessary for the prevention of illness. and hepatitis B for members at risk) are excluded unless they are directly related to the treatment of an injury or direct exposure to a disease or condition. • Influenza Vaccine (Flu) • BCG Vaccine • Pneumococcal Vaccine • Diphtheria/Tetanus/Acellular Pertussis Vaccine (ADACEL, (Pneumovax, Prevnar 13) BOOSTRIX, DAPTACEL, INFANRIX) • Hepatitis B Vaccine • Diphtheria/Tetanus/Acellular Pertussis/Inactivated Poliovirus (Recombivax, Engerix-B) Vaccine (KINRIX, QUADRACEL) for members at moderate • Diphtheria/Tetanus Vaccine (DT, Td, TDVAX, TENIVAC) to high risk • Diphtheria/Tetanus/Acellular Pertussis/Inactivated Poliovirus Vac­ • Other vaccines when directly cine/ Haemophilus Influenzae Type B Conjugate Vaccine (PENTACEL) related to the treatment of an • Diphtheria/Tetanus/Acellular Pertussis/Inactivated Poliovirus injury or direct exposure to a Vaccine/Hepatitis B Vaccine (PEDIARIX) disease or condition, such as: • Haemophilus Influenzae Type B Conjugate Vaccine (ActHIB, PedvaxHIB, • Antivenom Sera Hiberix) • Diphtheria/Tetanus Vaccine • Hepatitis A Vaccine, Inactivated (VAQTA) (DT, Td, TDVAX, TENIVAC) • Hepatitis B Vaccine, Recombinant (ENGERIX-B, RECOMBIVAX HB) • Rabies Virus Vaccine for members at low risk (RabAvert, Imovax Rabies) • Hepatitis A Inactivated, Hepatitis B Recombinant Vaccine (TWINRIX) • Human Papillomavirus 9—Valent Vaccine (GARDASIL 9) • Japanese Encephalitis Virus Vaccine (IXIARO) • Measles/Mumps/Rubella Vaccine (MMR II) • Measles/Mumps/Rubella/Varicella Vaccine, Live (PROQUAD) • Meningococcal Group B Vaccine—3 Strain (BEXSERO) • Meningococcal Group B Vaccine—4 Strain (TRUMENBA) • Meningococcal Conjugate Vaccine—MCV4 (MENACTRA, MENVEO) • Poliovirus Vaccine, Inactivated, IPV (IPOL) • Rabies Vaccine (IMOVAX Rabies, RabAvert) • Rotavirus Vaccine (ROTARIX, ROTATEQ) • Typhoid Vaccine (TYPHIM VI) • Varicella Zoster Vaccine Live (SHINGRIX, VARIVAX) • Yellow Fever Vaccine (YF-Vax)

CDPHP® is an HMO and PPO with a Medicare contract. Enrollment in CDPHP Medicare Advantage depends on contract renewal.

21-16978 April 2021