Key takeaways
- Medicare Part B and Medicare Advantage plans may cover allergy shots if a doctor deems them medically necessary for conditions like allergic rhinitis or asthma. An experienced healthcare professional must administer the shot in a clinical setting.
- While Medicare covers allergy shots, it does not extend to sublingual immunotherapy (tablets placed under the tongue) due to a lack of evidence supporting its effectiveness. The FDA has not yet approved most sublingual immunotherapy forms.
- Out-of-pocket costs for allergy shots under Medicare Part B include a 20% coinsurance after a person has paid their deductible. Coverage may cease after two years if clinical benefits are not observed.
Over-the-counter (OTC) treatments are available to help manage mild allergic reactions. However, chronic reactions that do not get better with OTC treatments may require subcutaneous immunotherapy.
Immunotherapy involves using allergy shots to reduce a person’s immune reaction to their trigger. They work by exposing an individual to tiny amounts of the allergen over time.
If a person’s doctor believes that allergy shots are medically necessary, Medicare may cover the treatment. This article explains the conditions and limitations of Medicare coverage of allergy shots.
Glossary of Medicare terms
- Out-of-pocket cost: This is the amount a person must pay for care when Medicare does not pay the total amount or offer coverage. Costs can include deductibles, coinsurance, copayments, and premiums.
- Premium: This is the amount of money someone pays each month for Medicare coverage.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before Medicare starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, coinsurance is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare may cover allergy shots when a doctor considers them medically necessary following appropriate diagnostic testing. Conditions for which Medicare will approve payment include:
- allergic conjunctivitis
- allergic rhinitis, or hay fever
- allergic asthma, so long as asthma symptoms are stable
- hypersensitivity to insect stings
- animal dander sensitivity
- mold-induced rhinitis
Medicare considers some uses of allergic immunotherapy to be investigational or experimental, which means they are not medically necessary. These uses include food allergies, nonallergic asthma, and migraine headaches.
For Medicare to cover allergy shots, a doctor with experience in immunotherapy must administer them. Medicare may request documentation confirming the suitability of a doctor to provide these services.
The shots should also take place in a clinical setting that can respond quickly to severe allergic reactions, which can be a side effect of allergy shots.
The duration of covered treatment varies among individuals, and Medicare will assess coverage on a case-by-case basis, according to a doctor’s advice. Medicare will consider a person’s preference, severity of the allergy, and response to previous treatment.
However, Medicare will stop paying for allergy shots if a person does not show evidence of clinical benefit after 2 years of treatment. The Centers for Medicare & Medicaid Services (CMS) defines the clinical benefit of allergic immunotherapy as:
- reduced symptoms
- increased tolerance to the particular trigger or allergen
- the use of less medication over time
Medicare Part B is outpatient medical insurance. Since allergy shots are administered on an outpatient basis, coverage would fall under Part B.
Once a person reaches their Part B deductible of $257, Part B pays for 80% of treatment costs, with the individual responsible for the remaining 20%.
Medicare Advantage, also called Part C, is an alternative to Original Medicare that includes the same coverage as parts A and B. Given this, Medicare Advantage plans would also cover allergy shots.
Private companies administer and sell these policies, so coverage may vary.
Medigap, or supplemental insurance, is private insurance that can help cover the out-of-pocket costs of Original Medicare, such as coinsurance or deductible payments. In the case of allergy shots, Medigap plans could help pay the 20% coinsurance of Part B.
The costs of allergy shots may vary depending on:
- a person’s level of coverage
- the components or allergens in the shot
- the frequency of the shots
- what the clinic charges as a consultant’s fee or administration fee
A 2021 study found that allergy shots generally cost around $748 to $849 per claim. Around 1 in 5 of these claims led to charges amounting to $1,000 or more, but the out-of-pocket costs were not clear from the data.
Medicare Part B covers allergy testing. As Medicare Advantage also includes Part B, this will also provide coverage for allergy tests.
Learn more about Medicare coverage for allergy testing.
Medicare Part B covers medically necessary allergy shots that meet certain criteria. Medicare also pays for prescription medications from Part D, which may include allergy medications.
Medicare does not pay for sublingual immunotherapy, as current evidence does not support its effectiveness in reducing most allergies.
The Food and Drug Administration (FDA) has not approved most forms of sublingual immunotherapy, in which an individual places a pill under the tongue for several minutes before swallowing it while it dissolves.
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
For Medicare to cover allergy shots, a doctor needs to confirm that previous treatments have not successfully reduced allergy symptoms and that the shots are medically necessary.
Allergy shot coverage falls under Part B. A person with Original Medicare typically covers 20% of the Medicare-approved cost of allergy shots after meeting their deductible.
Coverage may stop after 2 years if the individual is no longer getting clinical benefits.