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 members, Aetna Medicare Advantage plans will ensure members receive the COVID vaccine, including third doses and booster shots, at no cost to them as required by the CDC COVID-19 Vaccination Program.

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.

Aetna Medicare Advantage plans pay for the cost of the vaccine for all Medicare enrollees, regardless of whether they go to an in-network or out-of-network pharmacy or provider. Medicare Advantage members should show their Aetna member ID card when they get vaccinated.

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.

Yes, based on the expanded CDC guidance, Aetna will cover booster shots for members who qualify based on the following criteria:

Individuals who received the Moderna or Pfizer-BioNTech vaccine:

Criteria below apply for people who completed their primary vaccine series at least 6 months ago:

• People 65 years and older and residents in long-term care settings
• People aged 50 to 64 with certain underlying medical conditions
• People 18 to 49 who are at high risk for severe COVID-19 due to certain underlying medical conditions
• People aged 18-64 years who are at increased risk for COVID-19 exposure and transmission because of occupational or institutional setting

Individuals who received the Johnson & Johnson (Janssen) COVID-19 vaccine

• People 18 years and older who received their J&J vaccine at least 2 months ago

Eligible individuals may receive any vaccine (Pfizer, Moderna or J&J) as a booster dose. The CDC’s recommendations now allow for this type of mix and match dosing for booster shots. If members have questions about which booster shot is best for them, encourage them to consult their health care provider.

For Medicare beneficiaries, the Centers for Medicare & Medicaid Services (CMS) covers the cost of the vaccine booster dose for those who qualify. This includes those in a Medicare Advantage plan. As of January 1, 2022, Aetna Medicare Advantage plans will cover the cost of the vaccine booster for members who qualify.

Yes. Since a third dose of the Pfizer-BioNTech and Moderna vaccines is now recommended by the Centers for Disease Control (CDC) for individuals with weakened immune systems, the administration of a third mRNA COVID-19 vaccine is covered for those Aetna plan members. For Medicare beneficiaries, the Centers for Medicare & Medicaid Services (CMS) will cover the cost for the third vaccine dose for those who qualify. This includes those in a Medicare Advantage plan. As of January 1, 2022, Aetna Medicare Advantage plans will cover the cost of the vaccine booster for members who qualify.

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.

Yes. The FDA and CDC have now recommended that patients receiving the Johnson & Johnson (Janssen) vaccine receive a booster if the initial dose was received more than 2 months ago. The administration of this dose will be covered by Aetna.

If you are in one of the populations eligible for booster shots, it is recommended that you receive an additional dose to increase or "boost" your immune response to COVID-19. The effectiveness of the vaccines decreases over time and boosters restore immune response and reduce the risk of severe disease, hospitalization, and death. More information on booster shots is available from the CDC site.

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

According to the FDA and CDC, eligible individuals may receive any COVID-19 vaccine as a booster shot. CDC’s recommendations now allow for this type of mix and match dosing for booster shots.

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 a standard dose of the Pfizer BioNTech vaccine. Children 5-11 are now eligible for a pediatric dose of the Pfizer BioNTech vaccine.

Children ages 5-11 and 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.

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 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**,***
• 0003A - (Pfizer Admin): ADM SARSCOV2 30MCG/0.3ML 3RD - Rate: $40.00**,***
• 0004A - (Pfizer Admin): ADM SARSCOV2 30MCG/0.3ML BST - 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**,***
• 0013A - (Moderna Admin): ADM SARSCOV2 100MCG/0.5ML3RD - 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**
• 0034A - (Janssen): ADM SARSCOV2 VAC AD26 .5ML B- Rate $40.00**

* Facility or Provider reimbursement for Commercial plans may vary based on factors such as billed charges or contractual terms.

** 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.

Yes. As of September 2021, the CDC is strongly recommending that people who are pregnant or planning to become pregnant receive the COVID-19 vaccination. The CDC recommendations align with those from professional medical organizations serving people who are pregnant, including the American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine along with many other professional medical organizations. When unvaccinated pregnant people contract COVID-19, they may experience severe disease and higher rates of hospitalization, ICU admission and death than non-pregnant people. More information about COVID-19 vaccines while pregnant, breastfeeding or planning to become pregnant is available at the CDC COVID-19 Vaccines While Pregnant or Breastfeeding site.

The safety data shows no adverse complications in pregnancy related to the COVID-19 vaccination, including no association with having a miscarriage or impacts on fertility. More information about COVID-19 vaccines while pregnant, breastfeeding or planning to become pregnant is available at the CDC COVID-19 Vaccines While Pregnant or Breastfeeding.