Medicare relies on the rule of medical necessity when deciding whether to cover a service or treatment.
There is no set rule about Medicare covering allergy shots. The situation varies depending on many factors of your specific situation. This typically comes down to the fact that each person’s allergies are different and Medicare decides whether to provide coverage based on a designation of medical necessity, which is provided by your doctor. In other words, allergy shots may not be medically necessary for some people, even though they are for others.
What are the benefits of allergy shots?
Also known as immunotherapy shots, allergy shots are injections that help make your body less reactive to allergens. They work by desensitizing your immune system to an allergen by injecting very small doses of that particular allergen over a long period.
Allergy shots don’t provide immediate relief. Rather, they help you deal with your allergies over time. They can be very effective in the long run and are the only way to help you reach true immunity to your allergies. While getting allergy shots, you may still use other medications as directed by your doctor.
Not every type of allergy can be treated with immunotherapy shots. For example, food allergies do not respond to this treatment. The injections are most commonly used to treat seasonal and environmental allergies like pollen, dander, and mold, but can also be used for stinging insect allergies.
Allergy shots require you to go to your allergist or doctor’s office every week, and your provider will monitor you for around 30 minutes after each shot. This is a big time commitment, so make sure you understand what allergy shots entail before you commit to a course of treatment.
Which part of Medicare covers allergy shots?
When allergy shots are covered by Medicare, Part B applies, which covers your outpatient healthcare costs.
Medicare will not cover allergy shots for everyone. To receive coverage, your doctor will have to indicate that allergy shots are medically necessary for you. This means that allergy shots are the best way to deal with your allergies and are necessary for treating your condition.
People who have very mild allergies may not qualify. If your allergies are burdensome to you, your best bet is to discuss treatment options with your doctor. Even if you can’t get allergy shots, your provider can help you determine an appropriate treatment plan for your unique situation.
Will a Medicare Advantage plan pay for allergy shots?
Medicare Advantage, also known as Medicare Part C, is a way of receiving your Medicare benefits through a private insurance company. Medicare Advantage plans may offer more coverage or a lower cost, but also come with provider networks and other restrictions.
By law, Medicare Advantage plans are required to cover everything that Original Medicare (Parts A and B) cover. For this reason, you can expect the same level of coverage as under Part B. If your allergy shots are covered due to medical necessity, then they will be covered by Medicare Advantage as well.
If you are getting allergy shots or other allergy care through a Medicare Advantage plan, make sure to check that your provider is in the plan’s network.
Are allergy shots covered by Medicare Part D?
Medicare Part D is another part of Medicare that is offered by private companies. It is dedicated only to prescription drug coverage. Each Part D prescription drug plan covers different drugs at different costs, but none will cover allergy shots. This is because allergy shots are administered by your doctor. Part D covers self-administered prescribed medications, assuming the medication is included on your plan's drug formulary (i.e. drug list).
However, Part D plans may cover different allergy medications. If you want to see how much each medication will cost you, check your plan’s formulary and drug tier pricing. The tier a drug is on also helps you estimate how much a medication will cost out-of-pocket.
How much do allergy shots cost with Medicare?
Your costs for allergy shots will vary depending on whether you have Original Medicare or Medicare Advantage.
Under Original Medicare, you generally pay 20% of the Medicare-approved cost for covered services once you meet your Part B deductible. (In 2023, this deductible comes to $226.) You should be able to find out what this cost will be through your provider before you begin treatment.
If you have Medicare Advantage, your costs may vary depending on your plan. Each plan can have a different monthly premium, deductible, co-insurance, and co-pay. Under most Medicare Advantage plans, you will have a co-payment each time you go to get your allergy shots. Check with your plan for the details.
Can you pay for allergy shots with a Medicare Supplement plan?
Medicare Supplement plans, also known as Medigap plans, are private insurance policies that cover your out-of-pocket costs. They will not directly cover your allergy shots, or any medical care for that matter. However, some Medigap plans will pay for your Part B coinsurance. If you have to pay this as part of your allergy shots, then your Medigap plan may cover it.
Every Medigap plan covers your Part B coinsurance in full except for Plan K and Plan L, which cover 50% and 75% respectively.
Are allergy shots safe?
Allergy shots are safe when administered by a healthcare professional. A small minority of people may experience severe side effects such as anaphylaxis. The 30-minute monitoring session after receiving the shot allows patients to receive follow-up care quickly if this happens.
It is common to have some itching, sneezing, or irritation after your shot. Because you are being injected with the allergen, the effects will usually resemble allergic reactions. Most people have no severe side effects.
Medicare coverage for allergy testing
Before getting your allergy shots, you will most likely need to get some type of allergy test. There are different types of tests available that cater to different medical needs. The most common are prick tests, intradermal tests, patch tests, and blood tests. For most people, a simple and quick prick test can be done by an allergist to determine what you are allergic to.
Medicare will cover your allergy tests if they are deemed medically necessary by your doctor. If your doctor has determined that allergy shots are necessary for you, then allergy tests most likely will be as well. Nevertheless, talk to your doctor about whether they are necessary to get an answer that is specific to your situation.
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