aetna medicare travel insurance

Travel outside the U.S.

Medicare usually doesn’t cover health care while you’re traveling outside the U.S. There are some exceptions, including some cases where Medicare Part B (Medical Insurance) may pay for services that you get on board a ship within the territorial waters adjoining the land areas of the U.S. However, Medicare won't pay for health care services you get when a ship is more than 6 hours away from a U.S. port.

Medicare may pay for inpatient hospital , doctor , and  ambulance services  you get in a foreign country in these rare cases:

• You're in the U.S. when a medical emergency occurs, and the foreign hospital is closer than the nearest U.S. hospital that can treat your medical condition.
• You're traveling through Canada without unreasonable delay by the most direct route between Alaska and another U.S state when a medical emergency occurs, and the Canadian hospital is closer than the nearest U.S. hospital that can treat the emergency.
• You live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treat your medical condition, regardless of whether an emergency exists.

Medicare may cover medically necessary ambulance transportation to a foreign hospital only with admission for medically necessary covered inpatient hospital services.

Medicare drug coverage (Part D) covers all vaccines that the Advisory Committee on Immunization Practices (ACIP) recommends, including certain vaccines you might need to get before you travel outside the U.S. (like yellow fever, chikungunya, and Japanese encephalitis). Your Part D plan won't charge you a copayment or apply a deductible for vaccines ACIP recommends. Contact your Medicare drug plan for details and talk to your provider about which ones are right for you.

Your costs in Original Medicare

You pay 100% of the costs, in most cases. In the situations described above, you pay the part of the charge you would normally pay for covered services. This includes any medically necessary doctor and ambulance services you get in a foreign country as a part of a covered inpatient hospital stay. You also pay the coinsurance, copayments, and deductibles you'd normally pay if got these same services or supplies inside the U.S.

In the situations above, Medicare pays only for services covered under Original Medicare : Medicare Part A (Hospital Insurance) covers hospital care (care you get when you've been formally admitted with a doctor's order to the foreign hospital as an inpatient).

• Medicare didn't cover your hospital stay.
• You got ambulance and doctor services outside the hospital after your covered hospital stay ended.

Foreign hospitals aren’t required to file Medicare claims for your travel medical costs. You need to  submit an itemized bill  to Medicare for your doctor, inpatient, and ambulance services if both of these apply:

• You're admitted to a foreign hospital under one of the situations above
• The foreign hospital doesn't submit Medicare claims for you

To find out how much your test, item, or service will cost, talk to your doctor or health care provider. The specific amount you’ll owe may depend on several things, like:

• Other insurance you may have
• How much your doctor charges
• If your doctor accepts assignment
• The type of facility
• Where you get your test, item, or service

Things to know

The 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa are considered part of the U.S. Anywhere else is considered outside the U.S. 

Medicare drug plans don't cover prescription drugs you buy outside the U.S.

Medicare supplement insurance (Medigap) policies may cover emergency care when you travel outside the U.S.

Because Medicare has limited travel medical coverage outside the U.S., you may choose to buy a travel insurance policy to get more coverage. An insurance agent or travel agent can give you more information about the cost of travel medical insurance. Travel insurance doesn’t necessarily include health insurance, so it’s important to read the conditions or restrictions carefully.

Related resources

• Medicare & You: traveling abroad (video)

Is my test, item, or service covered?

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Will Medicare cover me if I travel outside the United States?

Kimberly Lankford,

Medicare doesn’t pay for medical services outside the United States or its territories, except in very limited circumstances, including if: 

• You experience a medical emergency while traveling between Alaska and another state and a Canadian hospital is closest to your location.
• You face a medical emergency while you’re in the United States or one of its territories, but the nearest hospital is across the border, for example in Canada or Mexico.
• You live in the United States or one of its territories and need hospital care, regardless of whether it’s an emergency, but the nearest hospital is in a foreign country.
• You need medical attention and you’re on a ship within six hours of a U.S. port.

Medicare covers all 50 states and the District of Columbia as well as U.S. territories American Samoa, Guam, the Northern Mariana Islands, Puerto Rico and the U.S. Virgin Islands.

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What kind of care outside the U.S. will Medicare cover?

In rare situations,  Medicare Part A  will cover inpatient hospitalization and  Medicare Part B  will cover emergency ambulance and doctor services immediately before and during your hospital stay. 

The same  deductibles, copayments and coinsurance  apply as for services in the U.S. But coverage is limited: Medicare won’t pay for ambulance or doctor services in the foreign country after your covered hospital stay ends.

If you qualify, the foreign hospital may file a claim with Medicare, but it’s not required to do so. In that case, you may need to  submit an itemized bill  to Medicare. If you receive care on a cruise ship within six hours of a U.S. port, the attending doctor usually submits the Medicare claim.

Do Medicare supplement policies cover foreign travel?

If you buy a private  Medicare supplement policy , better known as Medigap, you may be insured for foreign travel emergencies. Medigap plans C, D, F, G, M and N cover emergency health care while traveling outside of the country. But plans C and F are no longer available to new Medicare beneficiaries; only those eligible for Medicare before 2020 can enroll in plans C and F.

Medigap plans cover foreign travel emergency care that begins in the first 60 days of your trip. They pay 80 percent of the billed charges for specific medically necessary emergency care you receive outside the U.S., but you must first pay a $250 deductible for the year. Medigap’s foreign travel emergency coverage has a lifetime limit of $50,000.

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What other foreign travel emergency coverage is available?

Medicare Advantage.  Some  private Medicare Advantage plans  cover foreign travel emergency care, but here, too, coverage is limited and details vary. Find out more about the Medicare Advantage plans available in your area by using the  Medicare Plan Finder .

Travel insurance.  While some  travel insurance policies  cover trip cancellations, others also cover emergency medical care in a foreign country and medical evacuation either to a nearby medical facility or back to the U.S. However, some travel insurance policies exclude preexisting conditions, so find out about exclusions, coverage limits and other details before choosing a policy.

Tricare for Life.  If you’re a military retiree, you may have foreign-country health care coverage through Tricare for Life after you enroll in Medicare.  Tricare for Life  typically covers Medicare’s deductibles, copayments and coinsurance, but it also provides additional benefits, such as health care outside of the U.S. It’s the same foreign travel insurance military retirees and dependents have before enrolling in Medicare. You pay any deductibles and copayments for that coverage.

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Keep in mind

If you  plan to live abroad  or travel back and forth regularly, rather than just vacation out of the country, you can enroll in Medicare. But you’ll forgo coverage while you’re away and still have to pay the  monthly Part B premiums , typically $174.70 a month in 2024. You’ll also have to pay  Part A premiums  if you or your spouse haven’t paid Medicare taxes for at least 10 years.

If you decide to wait to enroll in Medicare until after you return to the United States, you may have to pay a  late enrollment penalty . If you work abroad and receive health insurance from your employer, live in a country with a national health system or volunteer and have health coverage through a sponsor organization, you may have some exemptions.

This includes eligibility for an eight-month special enrollment period after you stop working or lose your insurance; six months if you’re volunteering. It’s a good idea to research your options before making any decisions about health care insurance while traveling.

Return to Medicare Q&A main page

Kimberly Lankford is a contributing writer who covers Medicare and personal finance. She wrote about insurance, Medicare, retirement and taxes for more than 20 years at  Kiplinger’s Personal Finance  and has written for  The Washington Post  and  Boston Globe . She received the personal finance Best in Business award from the Society of American Business Editors and Writers and the New York State Society of CPAs’ excellence in financial journalism award for her guide to Medicare.

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Vaccines for Travel

• Clinical Policy Bulletins
• Medical Clinical Policy Bulletins

Number: 0473

Table Of Contents

Footnotes †   Persons who are immunocompromised because of immune deficiency diseases, leukemia, lymphoma, generalized cancer, or the acquired immunodeficiency syndrome, or who are receiving immunosuppressive therapy with corticosteroids, alkylating agents, anti-metabolites, or radiation.

Footnotes ††   LYMErix was withdrawn from the U.S. market in February 2002.

Footnotes *   Most Aetna benefit plans exclude coverage of vaccines for work.  Please check benefit plan descriptions.

Note : The Advisory Committee on Immunization Practices (1996) states that plague vaccination is not indicated for most travelers to countries in which cases of plague have been reported.

Experimental and Investigational

The following vaccines for travel are considered experimental and investigational (not an all-inclusive list):

• Malaria vaccine for travel because an effective malaria vaccine has yet to be developed.
• Oral or skin-patch cholera vaccine for prevention of entero-toxigenic Escherichia coli diarrhea because their clinical value has not been established.

Policy Limitations and Exclusions  

Note:  Most Aetna HMO plans exclude coverage of vaccines for travel.  Most Aetna traditional plans cover medically necessary travel vaccines for members of plans with preventive services benefits.  Please check benefit plan descriptions.

Note : Many of these vaccines may also be considered medically necessary for reasons other than travel, and may be covered when medically necessary in members with preventive benefits, regardless of whether the plan excludes coverage of travel vaccines.

The Centers for Disease Control and Prevention (CDC)'s recommended vaccinations for travelers can be found at the following website: Destinations and Travelers Health .

In a Cochrane review on vaccines for preventing malaria, Graves and Gelband (2006a) concluded that there is no evidence for protection by SPf66 vaccines against P. falciparum in Africa.  There is a modest reduction in attacks of P. falciparum malaria following vaccination with SPf66 in South America.  There is no justification for further trials of SPf66 in its current formulation.  Further research with SPf66 vaccines in South America or with new formulations of SPf66 may be justified.

In another Cochrane review, Graves and Gelband (2006b) concluded that the MSP/RESA (Combination B) vaccine shows promise as a way to reduce the severity of malaria episodes, but the effect of the vaccine is MSP2 variant-specific.  Pre-treatment for malaria during a vaccine trial makes the results difficult to interpret, particularly with the relatively small sample sizes of early trials.  The results show that blood-stage vaccines may play a role and merit further development.

Vaughan et al (2009) presented a comprehensive meta-analysis of more than 500 references, describing nearly 5,000 unique B cell and T cell epitopes derived from the Plasmodium genus, and detailing thousands of immunological assays.  This was the first inventory of epitope data related to malaria-specific immunology, plasmodial pathogenesis, and vaccine performance.  The survey included host and pathogen species distribution of epitopes, the number of antibody versus CD4(+) and CD8(+) T cell epitopes, the genomic distribution of recognized epitopes, variance among epitopes from different parasite strains, and the characterization of protective epitopes and of epitopes associated with parasite evasion of the host immune response.  The results identified knowledge gaps and areas for further investigation.  This information has relevance to issues, such as the identification of epitopes and antigens associated with protective immunity, the design and development of candidate malaria vaccines, and characterization of immune response to strain polymorphisms.

Currently, there is an ongoing phase III clinical trial of a candidate vaccine for malaria, but the study has not been completed (Birkett, 2010).

The Advisory Committee on Immunization Practices (ACIP) of the CDC provided the following recommendations regarding the prevention of plague (1996):

• Routine plague vaccination is not necessary for individuals living in areas in which plague is enzootic.
• Plague vaccination is not indicated for hospital staff or other medical personnel in such areas.
• Plague vaccination is not indicated for most travelers to countries in which cases of plague have been reported.

In a Cochrane review, Ahmed et al (2013) evaluated the safety, effectiveness, and immunogenicity of vaccines for preventing entero-toxigenic Escherichia coli (ETEC) diarrhea.  These investigators searched the Cochrane Infectious Disease Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, and ClinicalTrials up to December 2012.  Randomized controlled trials (RCTs) and quasi-RCTs comparing use of vaccines to prevent ETEC with use of no intervention, a control vaccine (either an inert vaccine or a vaccine normally given to prevent an unrelated infection), an alternative ETEC vaccine, or a different dose or schedule of the same ETEC vaccine in healthy adults and children living in endemic regions, intending to travel to endemic regions, or volunteering to receive an artificial challenge of ETEC bacteria were included for analysis.  Two authors independently assessed each trial for eligibility and risk of bias.  Two independent reviewers extracted data from the included studies and analyzed the data using Review Manager (RevMan) software.  They reported outcomes as risk ratios (RR) with 95 % confidence intervals (CI) and assessed the quality of the evidence using the GRADE approach.  A total of 24 RCTs, including 53,247 participants, met the inclusion criteria – 4 studies assessed the protective efficacy of oral cholera vaccines when used to prevent diarrhea due to ETEC and 7 studies assessed the protective efficacy of ETEC-specific vaccines.  Of these 11 studies, 7 studies presented efficacy data from field trials and 4 studies presented efficacy data from artificial challenge studies.  An additional 13 trials contributed safety and immunological data only.  The currently available, oral cholera killed whole cell vaccine (Dukoral®) was evaluated for protection of people against "travelers' diarrhea" in a single RCT in people arriving in Mexico from the USA.  These researchers did not identify any statistically significant effects on ETEC diarrhea or all-cause diarrhea (1 trial, 502 participants; low-quality evidence).  Two earlier trials, one undertaken in an endemic population in Bangladesh and one undertaken in people travelling from Finland to Morocco, evaluated a precursor of this vaccine containing purified cholera toxin B subunit rather than the recombinant subunit in Dukoral®.  Short-term protective efficacy against ETEC diarrhea was demonstrated, lasting for around 3 months (RR 0.43, 95 % CI: 0.26 to 0.71; 2 trials, 50,227 participants).  This vaccine is no longer available.  An ETEC-specific, killed whole cell vaccine, which also contains the recombinant cholera toxin B-subunit, was evaluated in people traveling from the USA to Mexico or Guatemala, and from Austria to Latin America, Africa, or Asia.  These investigators did not identify any statistically significant differences in ETEC-specific diarrhea or all-cause diarrhea (2 trials, 799 participants), and the vaccine was associated with increased vomiting (RR 2.0, 95 % CI: 1.16 to 3.45; 9 trials, 1,528 participants).  The other ETEC-specific vaccines in development have not yet demonstrated clinically important benefits.  The authors concluded that there is currently insufficient evidence from RCTs to support the use of the oral cholera vaccine Dukoral® for protecting travelers against ETEC diarrhea.  Moreover, they stated that further research is needed to develop safe and effective vaccines to provide both short- and long-term protection against ETEC diarrhea.

Also, an UpToDate review on "Travelers' diarrhea" (Wanke, 2014) states that "Use of vaccines to protect against travelers’ diarrhea is hindered by the varied pathogens that can cause it. Although enterotoxigenic E. coli (ETEC) predominates as an etiology of travelers’ diarrhea, vaccination strategies that have focused on this pathogen as a target have been suboptimal.  Although vaccination to protect against cholera is not routinely recommended for travelers, a number of trials suggest that the oral, killed whole-cell vaccine given with the nontoxic B subunit of cholera toxin (Dukoral) provides protection for travelers against ETEC infection.  The rationale for such protection is that the B subunit of cholera is antigenically similar to the heat-labile enterotoxin of ETEC.  In two randomized trials, the killed whole-cell vaccine combined with the B subunit of cholera toxin reduced the incidence of diarrhea caused by ETEC by 67 percent in a trial in Bangladesh and 52 percent among travelers to Morocco.  The Dukoral vaccine was approved in the United States in late 2006 for use as a travelers' diarrhea vaccine.  However, a conservative estimate that took into account the incidence of ETEC infection throughout the world and the efficacy of the vaccine suggested that it may prevent ≤7 percent of travelers' diarrhea cases.  The 2006 guidelines on travel medicine from the Infectious Diseases Society of America concluded that the decision to use the vaccine to prevent travelers' diarrhea must balance its cost, adverse effects, and limited utility against the known effectiveness and costs of self-treatment as described above.  A separate vaccination strategy for ETEC also appears to have limited utility.  Despite initial promising data on vaccination with heat-labile enterotoxin from ETEC via a skin patch, it was not effective in decreasing the incidence of moderate to severe diarrhea due to either ETEC or any cause in a randomized, placebo controlled trial that included 1,644 individuals who traveled to Mexico or Guatemala.  In a subgroup analysis, the vaccine provided modest protection against ETEC that produced only heat-labile enterotoxin (vaccine efficacy 61 percent [95 % CI, 7 to 84 percent]), but not ETEC that produced heat-stable toxin or both.  This highlights the limitations of a single-antigen vaccine for travelers’ diarrhea".

An UpToDate review on "Immunizations for travel" (Freedman and Leder, 2015) states that "In general, severely immunocompromised patients should not receive live vaccines.  Live vaccines include yellow fever vaccine, oral typhoid vaccine, nasal influenza vaccine, oral polio vaccine (OPV), MMR, and varicella vaccine.  Inactivated vaccines include meningococcal vaccine, parenteral typhoid vaccine, hepatitis A and B vaccines, rabies vaccine, Japanese encephalitis vaccine, inactivated influenza vaccine, inactivated polio vaccine (IPV), Tdap, and Td".

Chikungunya Vaccine

Chikungunya is primarily a mosquito-borne alphavirus caused by the chikungunya virus (CHIKV) that is often associated with fever and debilitating joint pain. Rarely, the virus can be transmitted via blood products, laboratory and maternal-fetal transmission. Outbreaks typically occur in tropical and subtropical regions of Africa, Asia, Oceania, and parts of the Americas and Europe where chikungunya virus-carrying mosquitos are endemic (Bettis et al, 2022; Wilson and Lenschow, 2022). Between 2014 and 2016, 3,941 cases were reported in the United States among travelers; 92% were associated with travel in the Americas (most commonly the Dominican Republic, Puerto Rico, and Haiti). The remaining 8% had traveled to Asia, Africa, or the Western Pacific (Lindsey et al, 2018; Wilson and Lenschow, 2022).

Management of the chikungunya virus is supportive (i.e., rest, fluids, antiinflammatory and analgesic agents). Systemic glucocorticoids or treatment with a disease-modifying antirheumatic drug (DMARD) has been used in refractory or chronic arthritis cases. The cornerstone of prevention has been minimizing mosquito exposure (Lenschow and Wilson, 2023). In November 2023, the FDA approved the first chikungunya vaccine (Ixchiq, Valneva Scotland Ltd) for the prevention of disease caused by chikungunya virus (CHIKV) in individuals 18 years of age and older who are at increased risk of exposure to CHIKV. "This indication is approved under accelerated approval based on anti-CHIKV neutralizing antibody titers. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory studies" (Valneva, 2023).

FDA approval was based on two clinical trials conducted in North America that evaluated the safety of Ixchiq in adults 18 years or older. In clinical studies, the most common solicited injection site reaction (greater than 10%) was tenderness (10.6%). The most common solicited systemic adverse reactions (greater than 10%) were headache (31.6%), fatigue (28.5%), myalgia (23.9%), arthralgia (17.2%), fever (13.5%) and nausea (11.2%). The effectiveness was based on immune response data from a clinical study conducted in the US in adults. "In this study, the immune response of 266 participants who received the vaccine was compared to the immune response of 96 participants who received placebo. The level of antibody evaluated in study participants was based on a level shown to be protective in non-human primates that had received blood from people who had been vaccinated. Almost all vaccine study participants achieved this antibody level" (FDA, 2023).

Ixchiq is administered as a single intramuscular injection. Ixchiq contains a live, weakened version of the chikungunya virus and may cause symptoms in the vaccine recipient similar to those experienced by people who have chikungunya disease. It is contraindicated in immunocompromised individuals or those with a history of a severe allergic reaction to any component of Ixchiq. Vertical transmission of wild-type CHIKV from pregnant individuals with viremia at delivery is common and can cause potentially fatal CHIKV disease in neonates. Vaccine viremia occurs in the first week following administration of Ixchiq, with resolution of viremia by 14 days after vaccination. It is not known if the vaccine virus can be vertically transmitted and cause fetal or neonatal adverse reactions. A decision to administer during pregnancy should take into consideration the individual’s risk of wild-type CHIKV infection, gestational age, and risks to the fetus or neonate from vertical transmission of wild-type CHIKV. Labeled warnings and precautions also include risk of syncope associated with administration of injectable vaccines (Valneva, 2023).

The Centers for Disease Control's (CDC) Advisory Committee on Immunization Practices (ACIP) met in October 2023 to discuss recommendations for the chikungunya vaccine. Draft recommendations include chikungunya vaccine recommendation for persons 18 years of age and older traveling to a country or territory where there is a chikungunya outbreak. In addition, the vaccine may be considered for persons traveling to a country or territory without an outbreak but with evidence of chikungunya virus transmission among humans within the last 5 years:

• Older persons (e.g., >65 years), particularly those with underlying medical conditions, who are likely to have at least moderate exposure (moderate exposure could include travelers who might have at least 2 weeks (cumulative) of exposure to mosquitoes in indoor and/or outdoor settings) to mosquitoes
• Persons staying for a cumulative period of 6 months or more during a 2-year period

Japanese Encephalitis Vaccine for Pediatric Travelers

Taucher and colleagues (2020) stated that in an initial study among children from non-Japanese encephalitis (JE)-endemic countries, sero-protection rates (SPRs) remained high 6 months following completion of the primary series with IXIARO. In an open-label, follow-up study, a subset of 23 children who received a 2-dose primary series of IXIARO in the parent study, were examined for safety and neutralizing antibody persistence for 36 months.  SPRs remained high but declined from 100 % 1 month after primary immunization to 91.3 % at month 7 and 89.5 % at month 36. Geometric mean titers (GMTs) declined considerably from 384.1 by day 56-60.8 at month 36.  No long-term safety concerns were identified.  The authors concluded that the substantial decline in GMT observed in this study, together with previously published data on children vaccinated with IXIARO supported the recommendation for a booster dose in children who remain at risk of JE from 1 year after the primary series of IXIARO, consistent with the recommendation for adults.

Jost and colleagues (2015) evaluated the relevance of travel-related measles, a highly transmissible and vaccine-preventable disease. Between 2001 and 2013, surveillance and travel-related measles data were systematically reviewed according to the PRISMA guidelines with extraction of relevant articles from Medline, Embase, GoogleScholar and from public health authorities in the Region of the Americas, Europe and Australia.  From a total of 960 records, 44 articles were included and they comprised 2,128 imported measles cases between 2001 and 2011.  The proportion of imported cases in Europe was low at 1 to 2 %, which reflected the situation in a measles-endemic region.  In contrast, imported and import-related measles accounted for up to 100 % of all cases in regions with interrupted endemic measles transmission; 11 air-travel related reports described 132 measles index cases leading to 47 secondary cases.  Secondary transmission was significantly more likely to occur if the index case was younger or when there were multiple infectious cases on board.  Further spread to health care settings was found.  Measles cases associated with cruise ship travel or mass gatherings were sporadically observed.  The authors concluded that within both, endemic and non-endemic home countries, pre-travel health advice should assess MMR immunity routinely to avoid measles spread by non-immune travelers.  They stated that to identify measles spread as well as to increase and sustain high vaccination coverages, joint efforts of public health specialists, health care practitioners and travel medicine providers are needed.

An UpToDate review on "Immunizations for travel" (Freedman and Leder, 2016) states that "Children traveling outside the United States should receive MMR vaccination sooner than the standard immunization schedule. Prior to departure, children 12 months of age or older should have received 2 doses of MMR vaccine separated by at least 28 days, with the first dose administered on or after the first birthday.  Children aged 6 to 11 months should receive 1 dose of MMR before departure.  MMR vaccination for adults is indicated for individuals born in 1957 or later in the United States (before 1970 in Canada; before 1966 in Australia) without evidence of immunity or without evidence of 2 doses of an adequate live vaccine at any time after age 12 months.  Although individuals born before 1957 in the United States are presumed to be immune (exceptions include United States healthcare workers and women of childbearing age), 2 doses of MMR vaccine spaced by 1 month should be strongly considered for unvaccinated individuals without other evidence of immunity who were born before 1957 (in the United States) and are traveling for purposes of healthcare or humanitarian work potentially entailing close contact with ill individuals.  MMR vaccination is contraindicated in pregnant and immunocompromised patients".

The CDC (2015) states that anyone who is not protected against measles is at risk of getting infected when they travel internationally. It recommends the following: Centers for Disease Control and Prevention .

• Infants 6 months through 11 months of age should receive 1 dose of MMR vaccine Footnotes for MMR vaccines for infants †
• Children 12 months of age and older should receive 2 doses of MMR vaccine separated by at least 28 days.
• Teenagers and adults who do not have evidence of immunity Footnotes for Acceptable presumptive evidence of immunity against measles * against measles should get 2 doses of MMR vaccine separated by at least 28 days.

Footnotes † Infants who get 1 dose of MMR vaccine before their first birthday should get 2 more doses (1 dose at 12 through 15 months of age and another dose at least 28 days later).

Footnotes * Acceptable presumptive evidence of immunity against measles includes at least one of the following: written documentation of adequate vaccination, laboratory evidence of immunity, laboratory confirmation of measles, or birth in the United States before 1957.

Contraindications and Precautions: Vaccine Recommendations and Guidelines of the ACIP .

Contraindications

• Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component
• Known severe immunodeficiency (e.g., from hematologic and solid tumors, receipt of chemotherapy, congenital immunodeficiency, or long-term immunosuppressive therapy Footnotes for deferred vaccine † or patients with human immunodeficiency virus [HIV] infection who are severely immunocompromised) Footnotes for HIV infected children *

Footnotes † Vaccine should be deferred for the appropriate interval if replacement immune globulin products are being administered.

Footnotes * HIV-infected children may receive varicella and measles vaccine if CD4+ T-lymphocyte count is greater than 15 %.

Precautions

• Moderate or severe acute illness with or without fever
• Recent (within 11 months) receipt of antibody-containing blood product (specific interval depends on product) Footnotes for immune globulin products †
• History of thrombocytopenia or thrombocytopenic purpura
• Need for tuberculin skin testing Footnotes for Measles vaccination *

Footnotes † Vaccine should be deferred for the appropriate interval if replacement immune globulin products are being administered

Footnotes * Measles vaccination might suppress tuberculin reactivity temporarily. Measles-containing vaccine can be administered on the same day as tuberculin skin testing. If testing cannot be performed until after the day of MMR vaccination, the test should be postponed for at least 4 weeks after the vaccination. If an urgent need exists to skin test, do so with the understanding that reactivity might be reduced by the vaccine.

Tick-Borne Encephalitis Vaccine

Rampa et al (2020) state that tick-borne encephalitis (TBE) is increasing in Europe and has become one of the most important causes of viral encephalitis, as well as the most frequent cause of viral meningitis, in Europe. The authors note that there is no antiviral treatment against TBE and that active vaccination is a practical preventive measure to reduce the number of cases. There are two inactivated virus vaccines licensed in Europe: FSME-Immun® (Pfizer), in some countries distributed as Ticovac®, and Encepur® (Bavarian Nordic). FSME-Immun is based on the TBE virus strain Neudoerfl (Nd), whereas Encepur is based on the TBE virus strain Karlsruhe-23 (K23). Both vaccines have a pediatric TBE vaccine variant. Thus, the authors conducted a systematic review (registered at PROSPERO (#CRD42020155737) and conducted in accordance with PRISMA guidelines) of the immunogenicity and safety of the tick-borne encephalitis vaccine (2009-2019). Of a total of 2464 records, 49 original research publications included evaluation for immunogenicity and safety. The authors found that TBE-vaccines showed adequate immunogenicity, good safety and interchangeability in adults and children with some differences in long-term protection (seropositivity in 90.6–100% after primary vaccination; 84.9%–99.4% at 5 year follow up). Primary conventional vaccination schedule (days 0, 28, and 300) demonstrated the best immunogenic results (99–100% of seropositivity). Mixed brand primary vaccination presented adequate safety and immunogenicity with some exceptions. After booster follow-ups, accelerated conventional and rapid vaccination schedules were shown to be comparable in terms of immunogenicity and safety. First booster vaccinations five years after primary vaccination were protective in adults aged less than 50 years, leading to protective antibody levels from at least 5 years up to 10 years after booster vaccination. In older vaccinees, 50 years and older, lower protective antibody titers were found. Allergic individuals showed an adequate response and immunosuppressed individuals a diminished response to TBE-vaccination. The authors concluded that the TBE-vaccination with Encepur or FSME-Immun to be highly immunogenic, well tolerated and in all studies except one to be interchangeable. Schedules should, if possible, use the same vaccine brand (non-mixed). TBE-vaccines are immunogenic in terms of antibody response but less so when vaccination is started after the age of 50 years. Age at priming is a key factor in the duration of protection. In terms of safety, the European, licensed vaccines were found to be well tolerated in both children (aged 1–17 years) and in adults, with local injection site reactions in 24.8% (4.3–54%) and systematic reactions in 30% (0.6–45.9%) of vaccinees. Vaccine related serious adverse events (SAE) were rare.

In February 2021, the U.S. FDA accepted for Priority Review Pfizer’s Biologics License Application (BLA) for TicoVac, its tick-borne encephalitis (TBE) vaccine for active immunization to prevent TBE in individuals 1 year of age and older. If approved, TicoVac would be the first vaccine in the U.S. to help protect adults and children who are visiting or living in TBE endemic areas. In line with Priority Review designation, the FDA will target an action within six months of the application submission date, with the anticipated Prescription Drug User Fee Act (PDUFA) action date expected for August 2021.

The BLA is based on results from "more than 40 years of experience and evidence outside the U.S. In clinical trials, the safety and immunogenicity of TicoVac was assessed across two age groups (1-15 years of age and 16-65 years of age). In these studies, pooled seropositivity rates were 99-100% in 1-15 year olds and 94-99% in adults >15 years following three doses. Clinical studies demonstrated that TicoVac was well-tolerated with no unexpected adverse events or vaccine-related serious adverse events observed. Subsequent real-world studies have shown that the vaccine is 96-99% effective in people who have received at least two doses of the vaccine, and two to three doses of the vaccine were shown to be sufficient to provide a long-lasting immune memory” (Pfizer, 2021b).

On August 13, 2021, the U.S. FDA approved Ticovac (Pfizer Inc.), tick-borne encephalitis (TBE) vaccine, for active immunization to prevent TBE in individuals 1 year of age and older. FDA approval was based on the safety and immunogenicity of Ticovac that were assessed cross two age groups (Study 209: 1 to15 years of age and Studies 213 and 690601: persons 16 years of age and older). In these studies, seropositivity rates were 99.5% in the group of 1 to 15 year olds and 98.7-100% in persons older than 15 years following three primary doses. Clinical studies demonstrated that Ticovac was generally well-tolerated with no unexpected adverse events or vaccine-related serious adverse events observed. The most common adverse reactions across both age groups were local tenderness, headache, local pain, fever, restlessness, fatigue, and muscle pain. Real-world studies from Austria have shown that the vaccine is 96-98.7% effective in people who have received at least three doses of the vaccine (Pfizer, 2021a, 2021c).

Two open-label, multi-center, follow-up studies which enrolled subjects who were seropositive 1 month after the third vaccination from Studies 213 (N=252, ages 16 through 65 at the time of first TICOVAC dose) and 209 (N=358, ages 1 through 15 at the time of first Ticovac dose) were conducted to assess the seropersistence of TBE antibodies after completion of the primary vaccination series and the antibody response to a booster administration. Three years after the primary series of Ticovac , neutralization test (NT) seropositivity in follow-up studies 223 and 700401 ranged from 82.9% to 100% depending on age. Following a booster dose the NT seropositivity rates were 100% (Pfizer, 2021a).

Vaccines for Pregnant Travelers

Nasser and colleagues (2020) noted that pregnant travelers and their offspring are vulnerable to severe outcomes following a wide range of infections. Vaccine-preventable diseases can have a particularly severe course in pregnant women, but little is known about the safety of travel vaccines in pregnant women. These investigators carried out a systematic review of all published literature concerning the safety of vaccines frequently given to travelers such as yellow fever, MMR (mumps, measles and rubella), influenza, Tdap (tetanus, diphtheria and pertussis), meningococcus, hepatitis A and B, rabies, polio, typhoid fever, tick-borne encephalitis and Japanese encephalitis vaccines.  They included case series, cohort studies and RCTs. For the meta-analysis, these researchers included only RCTs that compared the administration of a vaccine to placebo or to no vaccine.  Outcome measures included severe systemic adverse events (AEs), maternal outcomes related to the course of pregnancy, neonatal outcomes and local AEs. They calculated the RR and its 95 % CI as the summary measure. The safety of influenza vaccine is supported by high-quality evidence.  For Tdap vaccine, no evidence of any harm was found in the meta-analysis of RCTs. A slight increase in chorioamnionitis rate was reported in 3 out of 12 observational studies.  However, this small possible risk is far out-weighed by a much larger benefit in terms of infant morbidity and mortality. Meningococcal vaccines are probably safe during pregnancy, as supported by RCTs comparing meningococcal vaccines to other vaccines.  Data from observational studies support the safety of hepatitis A, hepatitis B and rabies vaccines, as well as that of the live attenuated yellow fever vaccine.  The authors found little or no data about the safety of polio, typhoid, Japanese encephalitis, tick-borne encephalitis and MMR vaccines during pregnancy.

Yellow Fever Vaccine Safety in Immunocompromised Individuals

de Araujo Lagos et al (2023) stated that yellow fever (YF) is an arbovirus with variable severity, including severe forms with high mortality; and vaccination is the most effective measure to protect against the disease . Non-serious and serious AEs have been described in immunocompromised individuals; however, previous studies have failed to show this association.  In a systematic review, these investigators examined the risk of AEs following YF vaccination in immunocompromised individuals compared with its use in non-immunocompromised individuals.  They carried out a literature search in the Medline, LILACS, Embase, SCOPUS, DARE, Toxiline, Web of Science and grey literature databases for publications until February 2021.  Randomized and quasi-randomized clinical trials and observational studies that included immunocompromised subjects (individuals with HIV infection, organ transplantation, cancer, who used immunosuppressive drugs for rheumatologic diseases and those on immunosuppressive therapy for other diseases) were selected.  The methodological quality of observational or non-randomized studies was assessed by the ROBINS-I tool.  These researchers carried out 2 meta-analyses, proportion and risk factor analyses, to identify the summary measure of RR in the studies that had variables suitable for combination.  A total of 25 studies were included, most with risk of bias classified as critical; 13 studies had enough data to perform the proposed meta-analyses; 7 studies without a comparator group had their results aggregated in the proportion meta-analysis, identifying an 8.5 % (95 % CI: 0.07 to 21.8] risk of immunocompromised individuals presenting AEs following vaccination; 6 cohort studies were combined, with an RR of 1.00 (95 % CI: 0.78 to 1.29).  Subgroup analysis was conducted according to the etiology of immunosuppression and was also unable to identify an increased risk of AEs following vaccination.  The authors concluded that it was not possible to affirm that immunocompromised individuals, regardless of etiology, had a higher risk AEs, following receiving the YF vaccine.

Zaire Ebolavirus Vaccine

The Ebola virus [Zaire ebolavirus (EBOV)] vaccine is a replication-competent, live, attenuated recombinant vesicular stomatitis virus (rVSV) vaccine. It contains a gene from the Ebola virus, not the whole virus, which means persons cannot become infected with EBOV from the vaccine. The vaccine is known as rVSVΔG-ZEBOV-GP Ebola vaccine, brand name Ervebo (manufactured by Merck). The vaccine was approved by the U.S. FDA on December 19, 2019, for the prevention of Ebola virus disease (EVD) caused by EBOV in people 18 years of age and older, based on the data from 12 clinical trials that included a total of 15,399 adults (CDC, 2021).

Study 3 (Ring vaccination study) was an open-label, randomized cluster (ring) vaccination study conducted in the Republic of Guinea during the 2014 outbreak. Each cluster was composed of contacts and contacts of contacts of individuals with laboratory-confirmed Ebola virus disease (EVD). Clusters were randomized to receive either an “immediate” vaccination or a 21-day “delayed” vaccination. In the primary efficacy analysis, 3,537 subjects 18 years of age and older were considered contacts and contacts of contacts of an index case with laboratory-confirmed EVD. Of these, 2,108 were included in 51 immediate vaccination clusters, and 1,429 were included in 46 delayed vaccination clusters. In the primary efficacy analysis, the number of cases of laboratory-confirmed EVD in subjects vaccinated in immediate vaccination clusters was compared to the number of cases in subjects in delayed vaccination clusters. Cases of EVD that occurred between Day 10 and Day 31 post-randomization of the cluster were included in the analysis. Vaccine efficacy was 100%; no cases of confirmed EVD were observed in the immediate vaccination clusters, and 10 confirmed cases of EVD were observed in a total of 4 delayed vaccination clusters between Day 10 and Day 31 post-randomization (Merck, 2019).

On February 26, 2020, the Advisory Committee on Immunization Practices (ACIP) recommended pre-exposure vaccination with Ervebo® for adults aged 18 years or older in the U.S. population who are at potential risk of exposure to EBOV. This recommendation includes adults who are responding or may respond to an outbreak of EVD; laboratorians or other staff working at biosafety-level 4 facilities in the United States; or healthcare personnel (HCP) working at federally designated Ebola Treatment Centers in the United States. HCP refers to all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including body substances (e.g., blood, tissue, and specific body fluids); contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air. These HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, physicians, technicians, clinical laboratory personnel, autopsy personnel, therapists, phlebotomists, pharmacists, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel) (CDC, 2021).

Ervebo (Merck Sharp & Dohme Corporation) is a vaccine indicated for the prevention of disease caused by Zaire ebolavirus in individuals 18 years of age and older. Immunization with Ervebo results in an immune response and protection from disease caused by Zaire ebolavirus. The relative contributions of innate, humoral and cell-mediated immunity to protection from Zaire ebolavirus are unknown.

Limitations of use include:

• The duration of protection conferred by Ervebo is unknown;
• Ervebo does not protect against other species of Ebolavirus or Marburgvirus;
• Effectiveness of the vaccine when administered concurrently with antiviral medication, immune  globulin (IG), and/or blood or plasma transfusions is unknown.

Ervebo is available as 1 mL suspension for injection supplied as a single-dose vial and is to be administered intramuscularly.

Ervebo label carries warnings and precautions for anaphylaxis. Vaccinated individuals should continue to adhere to infection control practices to prevent Zaire ebolavirus infection and transmission. Vaccine virus RNA has been detected in blood, saliva, urine, and fluid from skin vesicles of vaccinated adults; transmission of vaccine virus is a theoretical possibility. The most common injection-site adverse events were injection-site pain (70%), swelling (17%), and redness (12%). The most common systemic adverse events reported were headache (37%), feverishness (34%), muscle pain (33%), fatigue (19%), joint pain (18%), nausea (8%), arthritis (5%), rash (4%) and abnormal sweating (3%) (Merck, 2019).

The above policy is based on the following references:

• Ahmed T, Bhuiyan TR, Zaman K, et al. Vaccines for preventing enterotoxigenic Escherichia coli (ETEC) diarrhoea. Cochrane Database Syst Rev. 2013;7:CD009029.
• American Academy of Pediatrics Committee on Infectious Diseases. Poliovirus. Pediatrics. 2011;128(4):805-808.
• Arguin PM, Kozarsky PE, Reed C, eds. CDC Health Information for International Travel, 2008. St. Louis, MO: Mosby; 2007. 
• Bettis AA, L'Azou Jackson M, et al. The global epidemiology of chikungunya from 1999 to 2020: A systematic literature review to inform the development and introduction of vaccines. PLoS Negl Trop Dis. 2022;16(1):e0010069.
• Birkett A. MVI discusses what's on the horizon for malaria vaccine development. Bethesda, MD: The PATH Malaria Vaccine Initiative; 2010.
• Carroll ID, Williams DC. Pre-travel vaccination and medical prophylaxis in the pregnant traveler. Travel Med Infect Dis. 2008;6(5):259-275.
• Centers for Disease Control and Prevention (CDC), National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of High-Consequence Pathogens and Pathology (DHCPP), Viral Special Pathogens Branch (VSPB). Ebola vaccine: Information about Ervebo. Atlanga, GA: CDC; February 25, 2021. Available at:  https://www.cdc.gov/vhf/ebola/clinicians/vaccine/index.html. Accessed June 6, 2021.
• Centers for Disease Control and Prevention (CDC), National Center for Emerging and Zoonotic Infectious Diseases (NCEZID). Evidence to recommendations for chikungunya vaccine use among adult travelers. ACIP meeting; October 26, 2023. Available at: https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2023-10-25-26/02-Chikungunya-Hills-508.pdf. Accessed November 20, 2023.
• Centers for Disease Control (CDC). Rabies prevention -- United States, 1984. MMWR Morbid Mortal Wkly Rep. 1984;33(28):393-402, 407-408.
• Centers for Disease Control and Prevention (CDC). Inactivated Japanese encephalitis virus vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 1993;42(RR-1):1-15.
• Centers for Disease Control and Prevention (CDC). Prevention and control of meningococcal disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morbid Mortal Wkly Rep. 2000;49(RR-7):1-10.
• Centers for Disease Control and Prevention (CDC). Prevention of hepatitis A through active or passive immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morbid Mortal Wkly Rep. 1999;48(RR-12):1-37.
• Centers for Disease Control and Prevention (CDC). Recommendations for the use of Lyme disease vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 1999;48(RR-7):1-17, 21-25.
• Centers for Disease Control and Prevention (CDC). Recommendations of the Advisory Committee on Immunization Practices: Revised recommendations for routine poliomyelitis vaccination. MMWR Morbid Mortal Wkly Rep. 1999;48(27):590.
• Centers for Disease Control and Prevention (CDC). The Yellow Book. CDC Health Information for International Travel 2012. New York, NY: Oxford University Press; 2011.
• Centers for Disease Control and Prevention (CDC). The Yellow Book. CDC Health Information for International Travel 2018. New York, NY: Oxford University Press; 2017.
• Centers for Disease Control and Prevention (CDC). Travelers' health: Chapter 4: Travel-related infectious diseases: Hepatitis B. The Yellow Book. Atlanta, GA: CDC; reviewed July 1, 2019. Available at: https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/hepatitis-b. Accessed April 12, 2022.
• Centers for Disease Control and Prevention (CDC). Typhoid immunization. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morbid Mortal Wkly Rep. 1990;39(RR-10):1-5.
• Centers for Disease Control and Prevention (CDC). Update: Recommendations to prevent hepatitis B virus transmission -- United States. MMWR Morbid Mortal Wkly Rep. 1995:44(30):574-575.
• Centers for Disease Control and Prevention (CDC). Update: Recommendations to prevent hepatitis B virus transmission -- United States. MMWR Morbid Mortal Wkly Rep. 1999;48(2):33-34.
• Centers for Disease Control and Prevention. Prevention of plague: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 1996;45(No. RR-14).
• Cetron MS, Marfin AA, Julian KG, et al. Yellow fever vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2002. MMWR Morbid Mortal Wkly Rep. 2002;51(RR-17):1-11.
• de Araujo Lagos LW, de Jesus Lopes de Abreu A, Caetano R, Braga JU. Yellow fever vaccine safety in immunocompromised individuals: A systematic review and meta-analysis. J Travel Med. 2023;30(2):taac095.
• Fischer M, Lindsey N, Staples JE, Hills S; Centers for Disease Control and Prevention (CDC). Japanese encephalitis vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010;59(RR-1):1-27.
• Fraser A, Goldberg E, Acosta CJ, et al. Vaccines for preventing typhoid fever. Cochrane Database Syst Rev. 2007;(3):CD001261.
• Freedman D, Leder K. Immunizations for travel. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed March 2015; March 2016.
• Garcia Garrido HM, Wieten RW, Grobusch MP, Goorhuis A. Response to hepatitis A vaccination in immunocompromised travelers. J Infect Dis. 2015;212(3):378-385.
• Gautret P, Wilder-Smith A. Vaccination against tetanus, diphtheria, pertussis and poliomyelitis in adult travellers. Travel Med Infect Dis. 2010;8(3):155-160.
• Graves P, Gelband H. Vaccines for preventing malaria (blood-state). Cochrane Database Syst Rev. 2006b;(4):CD006199.
• Graves P, Gelband H. Vaccines for preventing malaria (SPf66). Cochrane Database Syst Rev. 2006a;(2):CD005966.
• Graves PM, Deeks JJ, Demicheli V, Jefferson T. Vaccines for preventing cholera: Killed whole cell or other subunit vaccines (injected). Cochrane Database Syst Rev. 2001;(1):CD000974.
• Houle SKD, Eurich DT. Completion of multiple-dose travel vaccine series and the availability of pharmacist immunizers: A retrospective analysis of administrative data in Alberta, Canada. PLoS One. 2019;14(1):e0211006.
• Hyle EP, Rao SR, Bangs AC, et al. Clinical practices for measles-mumps-rubella vaccination among US pediatric international travelers. JAMA Pediatr. 2020;174(2):e194515.
• Jelinek T. Ixiaro: A new vaccine against Japanese encephalitis. Expert Rev Vaccines. 2009;8(11):1501-1511.
• Jost M, Luzi D, Metzler S, et al. Measles associated with international travel in the region of the Americas, Australia and Europe, 2001-2013: A systematic review. Travel Med Infect Dis. 2015;13(1):10-18.
• Lamarche L, Taucher C. Travel vaccines: Update. Can Pharm J (Ott). 2020;153(2):72-73.
• Lenchow DJ, Wilson ME. Chikungunya fever: Treatment and prevention. UpToDate [online serial]. Waltham, MA: UpToDate; reviewd October 2023.
• Lindsey NP, Staples JE, Fischer M. Chikungunya Virus Disease among Travelers-United States, 2014-2016. Am J Trop Med Hyg. 2018;98(1):192-197.
• Marfin AA, Eidex RS, Kozarsky PE, Cetron MS. Yellow fever and Japanese encephalitis vaccines: Indications and complications. Infect Dis Clin North Am. 2005;19(1):151-168, ix.
• Merck Sharp & Dohme Corporation. Ervebo (Ebola Zaire vaccine, live) suspension for intramuscular injection. Prescribing Information. Whitehouse Station, NJ: Merck; 2019.
• Nasser R, Rakedzon S, Dickstein Y, et al. Are all vaccines safe for the pregnant traveller? A systematic review and meta-analysis. J Travel Med. 2020;27(2).
• Nelson NP, Link-Gelles R, Hofmeister MG, et al. Update: recommendations of the Advisory Committee on Immunization Practices for use of hepatitis A vaccine for postexposure prophylaxis and for preexposure prophylaxis for international travel. MMWR Morb Mortal Wkly Rep. 2018;67(43):1216-1220. 
• No authors listed. Cholera vaccine. MMWR Morbid Mortal Wkly Rep. 1988;37(40):617-618, 623-624.
• Pfizer Inc. Ticovac (tick-borne encephalitis vaccine), suspension for intramuscular injection. Prescribing Information. New York, NY: Pfizer; revised August 2021a.
• Pfizer Inc. U.S. FDA accepts for priority review Pfizer’s application for TicoVac (tick-borne encephalitis vaccine). Press Release. New York, NY: Pfizer; February 23, 2021. Available at: https://www.pfizer.com/news/press-release/press-release-detail/us-fda-accepts-priority-review-pfizers-application. Accessed June 7, 2021b.
• Pfizer Inc. U.S. FDA approves Ticovac, Pfizer's tick-borne encephalitis (TBE) vaccine. Press Release. New York, NY: Pfizer; August 13, 2021c.
• Rampa JE, Askling HH, Lang P, et al. Immunogenicity and safety of the tick-borne encephalitis vaccination (2009–2019): A systematic review. Travel Medicine and Infectious Disease. 2020;37:101876.
• Ritz N, Connell TG, Curtis N. To BCG or not to BCG? Preventing travel-associated tuberculosis in children. Vaccine. 2008;26(47):5905-5910.
• Schioler KL, Samuel M, Wai KL Vaccines for preventing Japanese encephalitis. Cochrane Database Syst Rev. 2007;(3):CD004263.
• Staples JE, Gershman M, Fischer M; Centers for Disease Control and Prevention (CDC). Yellow fever vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010;59(RR-7):1-27.
• Taucher C, Barnett ED, Cramer JP, et al. Neutralizing antibody persistence in pediatric travelers from non-JE-endemic countries following vaccination with IXIARO® Japanese encephalitis vaccine: An uncontrolled, open-label phase 3 follow-up study. Travel Med Infect Dis. 2020;34:101616. 
• U.S. Food and Drug Administration (FDA). FDA approves first vaccine to prevent disease caused by chikungunya virus. FDA News Release. Silver Spring, MD: FDA; November 13, 2023.
• Valneva Scotland Ltd. Ixchiq (chikungunya vaccine, live) solution for intramuscular injection. Prescribing Information. Livingston, United Kingdom; revised November 2023.
• Vaughan K, Blythe M, Greenbaum J, et al. Meta-analysis of immune epitope data for all Plasmodia: Overview and applications for malarial immunobiology and vaccine-related issues. Parasite Immunol. 2009;31(2):78-97.
• Wanke CA. Travelers' diarrhea. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed March 2014.
• Wilder-Smith A. Meningococcal disease in international travel: Vaccine strategies. J Travel Med. 2005;12 Suppl 1:S22-S29.
• Wilson ME, Lenschow DJ. Chikungunya fever: Epidemiology, clinical manifestations, and diagnosis. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed January 2022.
• Wong KK, Burdette E, Mahon BE, et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Cholera Vaccine. MMWR. 2017;66(18):482-485.

Policy History

Effective: 04/13/2001

Next Review: 05/09/2024

Review History

Definitions

Additional Information

Clinical Policy Bulletin Notes

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Colonial Penn Medigap Plans Review

Colonial Penn offers a variety of Medigap plans for eligible Medicare beneficiaries.

SeniorLiving.org is supported by commissions from providers listed on our site. Read our Editorial Guidelines

Colonial Penn’s Medigap plans offer a variety of benefits to seniors living across the country. Just be aware that Colonial Penn does things a little differently. If you want a quote or want to apply for coverage, you’ll need to talk to someone on the phone. For some, that’s a drawback, but not needing to navigate a website is refreshing for others. We’ll cover everything you need to know about Colonial Penn to decide if their Medicare supplement insurance is right for you.

Getting to Know Colonial Penn

Colonial Penn Life Insurance Company (also known as Colonial Penn) was founded more than 50 years ago by AARP co-founder Leonard Davis. The company has long been known for selling life insurance products right to consumers.

Although they specialize in whole life insurance policies for adults aged 18 to 85, Colonial Penn also offers Medicare supplement plans through a partnership with Bankers Life and Casualty. Bankers Life field agents sell the plans, while Colonial Penn underwrites them.

To give you an idea of the company’s size, Bankers Life paid out insurance claims to more than 300,000 Medicare supplemental insurance policyholders in 2018. 1

The Pros and Cons of Colonial Penn

Pros about colonial penn.

• They offer all 10 Medigap plans (what’s actually available to you may vary by state).
• They allow access to all providers that accept Medicare patients.
• They provide permanent coverage, even if you develop health problems later on.
• They offer life insurance plans.

Cons About Colonial Penn

• You can’t get online quotes.
• Policies are not available in Massachusetts.

Overview of Colonial Penn’s Medigap Plans

Insurance certainly isn’t something that most people get excited about. Trying to pick a plan can be confusing. The chart below outlines the 10 Medigap plans that Colonial Penn offers and the benefits of each plan to help you start your search and make things a bit easier.

*Plan F and Plan G are also offered as a more affordable high-deductible plan, but the deductible must be met yearly before coverage begins.

**Plans C and F are available only to people who became eligible for Medicare before January 1, 2020.

FYI: Not every plan is available in every state. With Colonial Penn, Plan C is only available in Arizona, Delaware, Georgia, Iowa, Illinois, Maryland, Nebraska, Nevada, New Jersey, Ohio, and South Carolina. Plan D is not available in Connecticut, Florida, Maine, Minnesota, New York, Pennsylvania, Vermont, or Wisconsin.

Which Colonial Penn Medigap Plan Is Right for Me?

Colonial Penn offers every type of Medigap plan out there. Knowing which one to pick can feel a bit overwhelming. Below, we’ll use scenarios and lifestyle preferences to try to outline which plan may be the best choice for you.

Seniors with a limited budget who don’t visit the doctor as often

Plan N is the least expensive Medigap plan for seniors in good health who have infrequent doctor appointments. This plan requires a $20 copay for every office visit and a $50 copay for ER visits. Unfortunately, anything you spend on Plan N copayments doesn’t count toward your annual Part B deductible.

Seniors who want basic yet comprehensive coverage

Many adults find that Medigap Plan A and Plan B meet their needs. These plans provide hospital coverage, hospice care , and home health care . Plus, they assist with copays for routine doctor appointments. The big thing you miss out on with A and B is skilled nursing facility care coinsurance.

Seniors with chronic health conditions and/or seniors with lots of appointments

Colonial Penn offers a high-deductible option for Plan F and Plan G . If you use medical services a lot, going with one of these plans can save you money. Your monthly premium is lower, and once you meet the deductible, your plan covers 100 percent. This is a great choice if you have frequent follow-ups or specialist appointments or if you expect to need surgeries. Of course, it’s only worth it if you anticipate meeting that deductible. Otherwise, you may be better off with regular Plan F or Plan G.

FYI: Medigap plans are standardized. Plan A from Humana, another provider we’ve reviewed , offers the same coverage as Plan A from Colonial Penn. When comparing providers, you want to focus on the extras, the customer service, and the cost.

Seniors who live in a skilled nursing facility or plan to move into one

Only plans C, D, F, G, and N limit costs associated with skilled nursing facilities . If you have a medical condition or disability that makes it so you’d benefit from a skilled nursing facility now or in the future, one of those plans could help you save money.

Seniors with the travel bug

Love to travel ? Plans C, D, F, G, M, and N also provide international emergency coverage. If you have family overseas that you like to visit or simply plan to see the world during retirement , obtaining that coverage makes a lot of sense.

Pro Tip: If you’re planning on travel, consider buying travel insurance in case of medical emergencies. Check out the best travel insurance for seniors before you head on your next adventure.

How Much Do Colonial Penn Medigap Plans Cost?

Colonial Penn does not offer online quoting, so the only way to find out the cost is to fill out a contact form and have an agent call you. While that might sound convenient if you prefer phone vs. online, it could very well lead to ongoing solicitation efforts. We all know how tough those can be to deal with!

We’ve seen it suggested that Colonial Penn’s rates are higher than those of other providers we’ve reviewed, like Aetna . However, the only way to know for sure would be to give Colonial Penn a call.

If you decide to call, you need to ask about more than just premiums for your first year. Find out how they handle rate increases and what those increases might look like for you.

Policy pricing will follow one of these methods: 2

• Community rated: Everyone receives the same premium, no matter their age. These plans are often the most cost-effective over time.
• Issue-age rated: Your premium is based on your age when you buy the policy. For most Medigap users, that’s 65. Prices will increase with inflation.
• Attained-age rated: Your premium starts lower and increases as you age. These tend to be the most expensive plans over time.

How to Buy a Colonial Penn Medigap Policy

The best time to purchase a Medigap policy is during your six-month Medigap open enrollment period. During this time, you have access to the best prices and policy options. Open enrollment starts on the first day of the month when you’re 65 or older and enrolled in Medicare Part B .

You can still purchase a Medigap policy after open enrollment. The difference is that the company will use medical underwriting, which means taking a close look at your medical history. For many seniors, this limits the policy options and affects rates. That’s why we think it’s best to enroll when you’re first eligible.

Did You Know? Plans C, F, and High-Deductible F are only available to individuals who were first eligible for Medicare before Jan. 1, 2020. 3

If you want to enroll with Colonial Penn (or just get more information), you can call 888-910-3133 or follow the steps below to have an agent contact you.

Get a quote for Colonial Penn Medigap plans

Filling out your contact form for Colonial Penn Medigap insurance

• What policies are available to me based on where I live?
• Can you give me quotes for all of my different plan options?
• How are rate increases calculated?
• Which plan would you recommend for me?
• Are any discounts available?
• Next, we recommend researching some other Medigap carriers and comparing their costs, customer service, and any extras to Colonial Penn’s.
• Use what you’ve learned to make a final decision. If you choose Colonial Penn, communicate your decision with your agent. They will provide you with the next steps so that you can officially apply and purchase a policy. You’ll also find out your payment options, such as checks, money orders, or bank withdrawals.

Final Thoughts on Colonial Penn

Colonial Penn and Bankers Life use knowledgeable insurance agents to provide quotes and sell their Medigap policies. While some might appreciate that personalized touch, for others, it just means the research will take some extra time. You’ll also need to hand over your contact information. Other popular Medigap providers we’ve reviewed, including Blue Cross Blue Shield and Aetna, make quotes instantly available online, and you can get those quotes anonymously. If you feel wary of handing out your contact info or prefer the online shopping experience, you might want to pass on Colonial Penn. But if you like the thought of handling it all over the phone, then Colonial Penn is worth looking into.

Frequently Asked Questions About Colonial Penn Medicare Supplement Insurance

Seniors who purchase a Medicare Supplement Plan D policy through Colonial Penn will receive a free membership to SilverSneakers and WholeHealth Living Membership features include access to over 16,000 participating fitness centers, fitness classes, and discounted related services.

If you enroll during your open enrollment period, a company must sell you a Medigap policy regardless of your health issues; you cannot be denied coverage. However, if you wait and enroll after that window ends, a company can charge you higher rates or deny coverage outright.

Medigap policies help you cover the out-of-pocket medical expenses that Original Medicare Part A and Part B stick you with. These costs include copays, deductibles, and coinsurance.

In general, no, you cannot lose your Medigap coverage, because it’s guaranteed to be renewable. However, your insurance company could drop you if you fail to pay premiums, if you provided false information on your application, or if the company goes bankrupt.

Bankers Life. (2021). What is Medicare Supplement insurance?

Medicare.gov. (2021). What’s Medicare Supplement Insurance (Medigap)?

CNO Financial Group. (2019). Bankers Life Now Sells Medicare Supplement Plan D Insurance .

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CVS Cuts Annual Profit Forecast and Flags Challenges in 2025, Shares Fall 18%

FILE PHOTO: A general view shows a sign of CVS Health Retail Pharmacy Customer Care Center, at CVS headquarters of CVS Health Corp in Woonsocket, Rhode Island, U.S. October 30, 2023. REUTERS/Faith Ninivaggi/File Photo

By Leroy Leo and Christy Santhosh

(Reuters) -CVS Health Corp slashed its annual profit forecast on Wednesday and flagged challenges for next year's health insurance plans for older adults, and its shares plunged more than 18% to a four-year low.

The U.S. healthcare conglomerate said it now expects 2024 adjusted earnings of at least $7.00 per share, down from its prior view of at least $8.30. CVS said it anticipates the surge in medical procedures that fueled higher costs for its Aetna health insurance unit to persist through the year.

CVS shares fell 18.3% to $55.36, putting the stock on track to lose over $15 billion in market value.

U.S. health insurers have had to contend with rising medical costs over the past few quarters due to higher demand for procedures, especially among older adults, that were delayed during the COVID-19 pandemic.

The company's challenges with medical costs were amplified by lower performance-based bonus payments this year, after the U.S. government cut Star Ratings on Aetna's Medicare Advantage plans for 2023. The ratings for a year determine the bonus payments paid the following year.

While costs were rising, CVS had also priced its 2024 Medicare Advantage plans aggressively to gain market share, analysts said.

"CVS is suffering as the (Medicare Advantage) enrollment winner in 2024 because medical utilization is spiking in that population," Morningstar analyst Julie Utterback said.

The company, which also has a large retail pharmacy chain and one of the largest U.S. pharmacy benefit managers (PBM), said it expects negative margins of around 3%-4% from Aetna Medicare Advantage business this year.

CVS said there was strong demand for biosimilar versions of AbbVie's Humira after its Caremark PBM removed the blockbuster branded rheumatoid arthritis drug from its list of reimbursed medicines on April 1.

The company said it saw more prescriptions for the biosimilars in the first three weeks of April than the whole of last year, when Humira lost exclusivity in the U.S.

Next year, CVS plans to improve its margins, Chief Financial Officer Thomas Cowhey said, with the company expecting a boost from better bonus payments after it was awarded improved Star Ratings for 2024 late last year.

But it is also facing challenges from the U.S. government's 2025 reimbursement rates that has disappointed providers of Medicare Advantage health plans, as well as from provisions in the government's Inflation Reduction Act.

Insurers take those rates and other factors like Star Ratings into account in setting prices on their plans, which they use for their government bids.

"The combination of those things just makes a tough year for 2025 pricing harder," Cowhey told investors and analysts on a call to discuss the results.

CVS's healthcare benefits segment, including the Aetna unit, recorded medical cost ratio - the percentage of premiums spent on healthcare - of 90.4% for the first quarter. That compared with 84.6% a year earlier, and above analysts' average estimate of 88.43%, according to LSEG data.

CVS' focus on improving margins could ease competition for other health insurers in 2025, Stephens analyst Scott Fidel said, adding that it should particularly benefit UnitedHealth, while also reducing pressure on Humana.

On an adjusted basis, the company reported a profit of $1.31 per share for the first quarter, below analysts' average estimate of $1.69.

(Reporting by Christy Santhosh and Leroy Leo in Bengaluru; Editing by Sriraj Kalluvila and Bill Berkrot)

Copyright 2024 Thomson Reuters .

Tags: United States

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State Farm Medicare Supplement Insurance 2024 Review

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State Farm sells Medigap policies in most states, and members have few complaints about the company. However, the prices could be lower, and competitors offer more opportunities for discounts or added perks with your policy.

M-F 9am-9pm ET, Sa 10am-9pm ET

Speak to a licensed insurance agent on askchapter.org

from askchapter.org

Plan types offered Medigap plan types the company generally offers (availability may vary by location). Options include Plans A, B, C, D, F, G, K, L, M and N

A, C, D, F, G and N.

NAIC complaint rate How often the company’s members file complaints about their policies as compared to the industry average, according to data from the National Association of Insurance Commissioners (NAIC). NerdWallet conducts its data analysis and reaches conclusions independently and without the endorsement of the NAIC.

Far fewer than expected

Premium discounts available Based on the number and size of a company’s available discounts on monthly premiums, in comparison to other insurance companies.

Below average

• Complaint rates over 60% below the market average.
• Competitive prices in some higher-cost locations.
• Few discounts or health and wellness perks.
• High premiums in some locations.

State Farm is probably best known for auto insurance, but the company also offers medical insurance products including Medicare Supplement Insurance, or Medigap.

State Farm sells Medigap policies in most states and members have few complaints about them. However, the prices could be lower in some locations, and competitors offer more opportunities for discounts or added perks with your policy.

Here’s what you need to know about State Farm Medicare Supplement Insurance.

State Farm Medicare Supplement Insurance

State Farm Medicare Supplement Insurance earned 4 stars out of 5 for overall performance. NerdWallet’s ratings are determined by our editorial team. The scoring formula takes into account pricing, coverage options, complaint data from the National Association of Insurance Commissioners and more.

Based on these ratings, State Farm Medicare Supplement Insurance is one of the highest rated options on our list of the best Medicare Supplement Insurance companies .

Still deciding on the right carrier? Compare Medigap plans

State farm medicare supplement insurance pros and cons.

State Farm’s Medigap offerings have advantages and disadvantages.

Minimal complaints: State Farm members file complaints at rates 61% below the average for all Medigap insurance companies on the market.

Low prices in certain locations: Premiums in Los Angeles, a high-cost location, were the lowest on the market.

Not many perks or discounts: State Farm doesn’t keep up with competitors that offer various discounts on premiums and added perks like fitness benefits.

High prices in certain areas: In some locations, you can find significantly lower prices on plans from State Farm’s competitors, even before discounts.

State Farm Medicare Supplement Insurance plans

State Farm offers four Medicare Supplement Insurance plans available for purchase by any Medicare beneficiary in most states:

Medigap Plan A — the basic benefits included in every Medigap plan without any extras.

Medigap Plan D — a middle cost option that covers most Medigap benefits.

Medigap Plan G — the highest-coverage option available to new Medicare members.

Medigap Plan N — a plan with lower premiums but higher copays.

State Farm also offers Medigap Plan C and Medigap Plan F for qualifying beneficiaries who were eligible to enroll in Medicare prior to 2020. Newer Medicare members can’t buy these plans from any company.

In addition, State Farm offers Medicare Supplement Insurance in Minnesota and Wisconsin that fits each state’s respective standards, which differ from the standardization system used in the majority of the country.

Select your state on State Farm’s website to see the Medigap plan types available in your location.

Cost for State Farm Medicare Supplement Insurance

The following price estimates were obtained for three metropolitan areas representing above-average, average and below-average costs for the most popular Medicare Supplement Insurance plans (Plan G and Plan N) [0] NerdWallet analysis of American Association for Medicare Supplement Insurance data . Best Costs Medigap 2024 – Plan G . Accessed Feb 9, 2024. View all sources :

Los Angeles: More expensive than average.

Atlanta: Average cost for the U.S.

Dallas: Less expensive than average.

The sections below show estimated pricing information from State Farm for a 65-year-old female nonsmoker as filed with the Centers for Medicare & Medicaid Services [0] Centers for Medicare & Medicaid Services . Find a Medigap Policy That Works For You . Accessed Jan 10, 2024. View all sources . (Note: Some Medigap prices may be higher for males.)

For comparison, each table also includes the price for the least-expensive option to buy the same plan from any company that filed prices. For example, State Farm’s lowest estimated price for Medigap Plan G in Los Angeles appears alongside the lowest price on Medicare.gov for all Plan G policies available in Los Angeles to an applicant with identical demographics.

On average, State Farm’s quoted prices for Medigap Plan G were about 24% higher than the least-expensive Plan G policy in the area.

On average, State Farm’s quoted prices for Medigap Plan N were about 23% higher than the least-expensive Plan N policy in the area.

Some Medicare Supplement Insurance companies might offer premium discounts to qualifying enrollees who, for example, bundle multiple kinds of insurance, set up autopay or live with another adult who has a Medigap policy from the same company.

State Farm doesn’t advertise premium discounts specific to its Medigap policies.

State Farm member complaints

61% fewer complaints than average.

State Farm members file complaints about their Medicare Supplement Insurance policies 61% less often than the average for all Medigap insurance companies, according to 2022 data from the National Association of Insurance Commissioners for State Farm [0] National Association of Insurance Commissioners . Company Complaint Index . Accessed Jan 10, 2024. View all sources .

NerdWallet conducts its data analysis and reaches conclusions independently and without the endorsement of the NAIC.

State Farm’s spending on care

75% for member benefits.

Medicare Supplement Insurance companies must report data on the premiums they collect and how much they spend to provide benefits for members.

Based on the most recent year of data, State Farm Medicare Supplement Insurance plans spend about 75% of premiums on member benefits [0] National Association of Insurance Commissioners . 2022 Medicare Supplement Insurance Experience Reports (Direct Premiums Earned; Direct Claims Incurred) . Accessed Feb 9, 2024. View all sources . (The other 25% goes to overhead expenses like administrative costs, marketing, salaries and commissions.)

For comparison, the average for all companies is 80.4%. The minimum required by law for individual Medigap policies is 60% [0] Code of Federal Regulations . Title 42, Part 403, Section 215 . Accessed Jan 10, 2024. View all sources .

Additional benefits

Medigap plans have standardized Medicare benefits, but insurance companies can offer additional perks. While some competitors offer extra benefits like gym memberships or discounts on hearing aids and eyewear, State Farm doesn’t publicize similar extras for its Medicare Supplement Insurance policies.

State Farm Medicare Supplement Insurance service area

State Farm offers Medicare Supplement Insurance in 45 states and Washington, D.C. (State Farm doesn’t offer Medigap policies in Connecticut, Massachusetts, New Jersey, New York or Rhode Island.)

As of the end of 2022, State Farm covered about 103,000 Medigap beneficiaries and had about a 0.9% share of the total Medicare Supplement Insurance market [0] National Association of Insurance Commissioners . 2022 Medicare Supplement Loss Ratios . Accessed Feb 9, 2024. View all sources .

State Farm Medigap customer service

Here’s how State Farm Medigap members can contact customer service:

Contact your local State Farm agent.

Call State Farm at 800-782-8332 (TTY ​​dial 711 and follow the prompts).

Compare Medicare Supplement Insurance companies

Get more information below about some of the major Medicare Supplement Insurance companies. These insurers offer Medigap plans in most states, but specifics may vary depending on your location.

AARP/UnitedHealthcare Medicare Supplement Insurance .

Aetna Medicare Supplement Insurance .

Anthem Medicare Supplement Insurance .

Cigna Medicare Supplement Insurance .

Humana Medicare Supplement Insurance .

Mutual of Omaha Medicare Supplement Insurance .

State Farm Medicare Supplement Insurance .

About State Farm

State Farm, headquartered in Bloomington, Illinois, was founded in 1922 to provide auto insurance to rural customers. Its lines of business have since grown to include home, business, life, health and disability insurance, as well as banking, investing and other financial services. Medicare Supplement Insurance is State Farm’s only Medicare product.

Find the right Medicare Supplement Insurance plan

Because Medigap plans are standardized, you can get precisely the same Medicare benefits from any company offering the plan. So when you shop, keep these considerations in mind to find the best policy to fit your needs:

Is your preferred plan available? Health insurance companies don’t always sell every plan, so check who sells the plan you want to buy in your area.

What are the premiums? Prices for the same plan can vary between companies, so check to find the most competitive rates.

Will your premiums change over time? Most policies cost more as you age, but some companies offer policies that let you lock in a price when you sign up.

Are there extras? Medigap plans’ core benefits are standardized, but in certain cases, some companies include such perks as discount programs or gym memberships.

Medicare Supplement Insurance ratings methodology

NerdWallet’s Medicare Supplement Insurance (Medigap) ratings are based on pricing, discounts, plan types offered, complaint data from the National Association of Insurance Commissioners, consumer experience, additional perks and benefits, and more. To calculate each health insurance company's rating, we adjusted the scores to a curved 5-point scale, rounded to the nearest half star.

NerdWallet reviewed 13 Medicare Supplement Insurance companies based on highest enrollment and greatest online search volume. These ratings are a guide, but we encourage you to shop around and compare several insurance quotes to find the best coverage and rate for you. NerdWallet does not receive compensation for any reviews. Read our editorial guidelines and full ratings methodology for Medicare Supplement Insurance.

Insurer complaints methodology

We examined complaints received by state insurance regulators and reported to the National Association of Insurance Commissioners. To assess how insurers compare to one another, the NAIC calculates a complaint index each year for each subsidiary, measuring its share of total complaints relative to its size, or share of total premiums in the industry. To evaluate a company’s complaint history, we calculated a similar index for each insurance company, weighted by market shares of each subsidiary. We score companies based on this index of how many complaints the company receives relative to its market share. NerdWallet conducts its data analysis and reaches conclusions independently and without the endorsement of the NAIC.

More on NerdWallet.com

Best Medicare Supplement Insurance Companies

Best Medicare Supplement Plan G Companies

Compare Medicare Supplement Insurance Plans

Medigap Plan G vs. Plan N: Which Is Best?