COVID-19: Vaccine FAQs

No. Aetna 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.

No. Aetna 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 Aetna member ID card – when you get vaccinated. This will help your health care provider or pharmacy to bill Medicare.

Consistent with CARE Act requirements, Aetna plans cover any COVID-19 vaccine that has received FDA authorization or approval, at no added cost to members.

The Pfizer-BioNTech vaccine has been fully approved by the FDS for individuals aged 16 and older and the FDA Emergency Use Authorizations for the Moderna and Johnson and Johnson (Janssen) COVID-19 vaccines and the Pfizer-BioNTech COVID-19 vaccine for individuals aged 12-15 remain in effect.

Both the Pfizer-BioNTech and Moderna vaccines have two doses, with the second dose coming a few weeks after the first. Pfizer-BioNTech’s second dose comes three weeks after the first, and Moderna’s comes four weeks later. The second dose gives people a strong, long-lasting immunity and it is recommended that individuals get both doses of the same vaccine.

Providers will need to ensure that individuals who got the first shot receive a second shot of the right vaccine at the right time.

CMS has provided additional guidance to plans, states and providers to ensure that the statutory requirements related to COVID-19 vaccination and coverage of administration costs are implemented as Congress intended. CMS issued the payment allowances and related information, including the rates listed below, for administering COVID-19 vaccines during the Public Health Emergency. The rates apply to Medicare and Medicaid. For Commercial plans, we are seeking wherever possible to apply rates that do not exceed these CMS rates*.

COVID-19 vaccine administration reimbursement rates:

• 0001A - (Pfizer Admin): ADM SARSCOV2 30MCG/0.3ML 1ST - Rate: $40.00**^†
• 0002A - (Pfizer Admin): ADM SARSCOV2 30MCG/0.3ML 2ND - Rate: $40.00**^†
• 0011A - (Moderna Admin): ADM SARSCOV2 100MCG/0.5ML1ST - Rate: $40.00**^†
• 0012A - (Moderna Admin): ADM SARSCOV2 100MCG/0.5ML2ND - Rate: $40.00**^†
• 0021A - (AstraZeneca): ADM SARSCOV2 5X10^10VP/.5ML 1 - Rate: $40.00**
• 0022A - (AstraZeneca): ADM SARSCOV2 5X10^10VP/.5ML 2 - Rate $40.00**
• 0031A - (Janssen): ADM SARSCOV2 VAC AD26 .5ML - Rate $40.00**

Aetna updated its Market Fee Schedule on March 15, 2021 to reflect the current CMS payment allowances.

*Hospital reimbursement for Commercial plans may differ (the allowed may be higher than CMS)

**CMS indicates that their rates will also be geographically adjusted for many providers. Visit the CMS website for more information.

^†Some states, such as Massachusetts, may require rates for Medicaid and Commercial plans that are higher or lower than CMS rates.

Per guidance provided by CMS, Medicare beneficiaries enrolled in MA plans can access the COVID-19 vaccine, without cost sharing, at any Fee for Service provider or supplier participating in Medicare and eligible to bill under Part B for vaccine administration, including those enrolled in Medicare as a mass immunizer or a physician, non-physician practitioner, hospital, clinic or group practice. Providers should submit claims for administration of the COVID-19 vaccine to the CMS Medicare Administrative Contractor (MAC) for payment.

For Commercial plan members, providers should submit claims for administering the COVID-19 vaccine to an Aetna member, and associated billing codes, to Aetna for payment. However, it is not necessary for providers to submit claims, or an associated billing code, for the COVID-19 vaccine itself to Aetna.

COVID-19 vaccinations will be available at pharmacies as well as doctors’ offices at other clinical sites of care. The list of pharmacies participating with the federal government in the administration of the vaccine can be found on the CDC website. Additionally, VaccineFinder is a free online service operated by Boston Children’s Hospital, in partnership with CDC, that has information on COVID-19 vaccine availability at certain providers and pharmacies in some states.

Our State Resource lookup tool provides links to each state’s health department and vaccine resource page, so you can get the latest information about when and where vaccines will be available in your area.

You can also visit CVS.com for the latest updates on availability at CVS locations in your area.

Aetna follows the guidance provided by the CDC and FDA regarding the age of eligibility to receive the vaccine. Right now, children over the age of 12 are eligible to receive the Pfizer BioNTech vaccine.

Adolescents over age 12 can receive a Pfizer BioNTech vaccine through many of the vaccination locations already providing vaccines today, including pharmacies, health systems, and local vaccination clinics and events. Vaccine distribution strategies vary by state, so we encourage you to check your state’s vaccine website for more information. Our State Resource lookup tool provides links to each state’s health department and vaccine resource page, so you can get the latest information about where Pfizer BioNTech vaccines are available in your area.

The FDA and the CDC are confident that the vaccine is safe and effective against COVID-19. At this time, the available data suggests that the chance of developing a rare blood disorder – thrombosis with thrombocytopenia syndrome (TTS) – is very low, and the benefits of the vaccine outweigh the risks.

For women between the ages of 18 and 49, this adverse event is rare, occurring at a rate of about 7 per 1 million vaccinated women. For women 50 years and older and men of all ages, this adverse event is even more rare. Women younger than 50 should be aware that other COVID-19 vaccines are available where this risk has not been seen.

Patients who receive the Janssen vaccine should monitor for severe headache, abdominal pain, leg pain or shortness of breath for 2 weeks after administration.

If experiencing symptoms, patients should contact their health care provider.