Does Medicare Cover Allergy Shots and Their Costs?

Allergy shots, also known as immunotherapy, aim to reduce sensitivity to specific allergens by introducing small, increasing doses over time. This article clarifies how Medicare provides coverage for allergy shots and the associated financial responsibilities.

Original Medicare Coverage for Allergy Shots

Original Medicare Part B covers medically necessary allergy shots. Part B covers outpatient medical services, including allergy immunotherapy. For coverage to apply, a healthcare provider must determine that the allergy shots are medically necessary.

Part B generally covers the allergy serum itself, the professional service of administering the injections, and any related office visits required for the treatment. This coverage is predicated on the shots being administered in a clinical setting equipped to handle potential severe allergic reactions, which can occur as a side effect. Medical documentation must support the need for immunotherapy, often detailing the specific allergens being treated and the planned dosage regimen.

Medicare Part A, which primarily covers inpatient hospital care, and Part D, which covers self-administered prescription drugs, are generally not applicable to allergy shots. Since these shots are typically administered in an outpatient setting by a healthcare professional and are not self-administered medications, they fall outside the scope of Part A and Part D benefits. Coverage may continue for several years, but Medicare might reassess necessity if clinical benefits are not observed after a certain period, such as two years.

Medicare Advantage Plan Coverage for Allergy Shots

Medicare Advantage Plans, also referred to as Medicare Part C, are offered by private insurance companies that have received approval from Medicare. These plans are mandated by law to provide at least the same level of coverage as Original Medicare, which includes medically necessary allergy shots. Consequently, if Original Medicare Part B covers your allergy shots, a Medicare Advantage Plan will also include this coverage.

There are distinctions in how Medicare Advantage plans deliver this coverage compared to Original Medicare. Many Medicare Advantage plans, such as Health Maintenance Organizations (HMOs) or Preferred Provider Organizations (PPOs), may have network restrictions. HMOs typically require beneficiaries to use in-network providers for coverage, while PPOs offer more flexibility but may impose higher costs for out-of-network services.

Additionally, Medicare Advantage plans often require prior authorization for certain services, including allergy shots. This means the plan must approve the treatment before it is administered for coverage to be guaranteed. Beneficiaries should consult their specific plan’s Evidence of Coverage document or contact the plan directly to ascertain precise coverage rules, network requirements, and any unique cost-sharing arrangements.

Understanding Costs and Payment Responsibilities

When receiving allergy shots under Original Medicare Part B, beneficiaries are responsible for certain out-of-pocket costs. For 2025, the annual Part B deductible is $257. After this deductible has been met, Medicare typically covers 80% of the Medicare-approved amount for the services, leaving the beneficiary responsible for the remaining 20% coinsurance.

The costs associated with Medicare Advantage plans for allergy shots can fluctuate significantly depending on the specific plan chosen. These plans may involve different copayments or coinsurance amounts per visit or for the shots themselves. Unlike Original Medicare, Medicare Advantage plans are required to have an annual out-of-pocket maximum, which caps the total amount a beneficiary might pay for covered services in a year.

For individuals with Original Medicare, supplemental insurance policies, commonly known as Medigap plans, can assist in covering the 20% coinsurance. Medigap policies are sold by private companies and are designed to help pay for costs not covered by Original Medicare, such as deductibles and coinsurance. It is advisable for beneficiaries to confirm their specific out-of-pocket costs with their healthcare provider and their Medicare plan before beginning treatment to avoid unexpected financial obligations.