Medicare Part D
MEDICARE UPDATE: New information regarding payment of administration fees for vaccines covered by Medicare Part D.
- The Tax Relief and Health Care Act (TRHCA) of 2006, enacted by the federal government on 12/20/06, requires that Medicare providers be reimbursed for the administration of vaccines covered by Part D beginning 1/1/07.
- Per TRHCA, Part B will cover the administration fees in 2007 only, while Part D will cover for 2008 and thereafter.
- Both Medicare enrolled physicians and pharmacies enrolled with the National Supplier Clearinghouse are eligible to receive Part D administration fee reimbursement.
- Medicare Part B co-pays and deductibles apply to administration fees paid by Medicare Part B for administration of a Medicare Part D covered vaccine.
With the passage of TRHCA, healthcare providers could submit for reimbursement for the administration of a Part D covered vaccine through Medicare Part B for 2007, and then through Medicare Part D thereafter. Unless the enrollee’s Part D plan had established an alternative process, for Part D vaccines administered in a physician’s office the enrollee was still required to pay the physician for the vaccine product cost and then submit a paper claim to their Part D Drug Plan for reimbursement.
Vaccines and Medicare Part D
This page is intended to help explain the vaccine reimbursement claims process for Medicare Part D. Following these steps does not guarantee that reimbursement will cover an individual patient’s costs for the vaccine product. You should contact health plans directly to ensure that you have the most accurate and timely information on the reimbursement, patient out-of-pocket costs, and correct billing processes.
Certain adult vaccines may be eligible as a pharmacy benefit and may be reimbursed under Medicare Part D, including Medicare Advantage Prescription Drug Plans (MA-PDs), which carry medical and prescription drug benefits. Medicare Part D plans that have added a vaccine to their formulary may require the patient to initially pay the full cost of the vaccine, and then submit a paper claim requesting reimbursement from the patient’s Medicare Part D plan.
Claims submission steps
- Step 1 Contact the patient’s PDP or MA-PD to determine patient-specific reimbursement coverage status, co-pay information, claim submissions process, paper claim submission and any alternative claim submission procedures.
- Step 2 Collect all applicable charges from the patient.
- Step 3 Follow the claim submission steps outlined by the health plan.
Department of Health and Human Services, Centers for Medicare & Medicaid Services Federal Register, Volume 70, Number 18, January 28, 2005, provides additional information regarding vaccines and Medicare Part D.
Medicare prescription drug plan directory
Information was collected for a number of Medicare prescription drug plans (PDPs) and Medicare Advantage prescription drug (MA-PD) plans. Where available, the plan website, phone number and formulary or claim-form availability was recorded. This was not a complete list of PDP and MA-PD plans. Plan addresses and telephone numbers are reproduced as they were recorded in 2006–2007 and are not links.
PDPs
- Aetna (FL)
- Detail
- No plan detail was recorded on this page.
- Humana
- Website
- www.humana-medicare.com
- Formulary
- Available
- Claim form
- N/A
- Phone
- 800.555.CLIN (2546)
- Coventry Health Care
- Website
- www.firsthealthpremier.com
- Formulary
- Available
- Claim form
- N/A
- Phone
- 866/823-5177
- Caremark, Inc.
- Website
- www.silverscript.com
- Formulary
- Available
- Claim form
- Available
- Phone
- 866.235.5660
- Torchmark Corp
- Website
- www.uamedicarepartd.com/default.asp
- Formulary
- Available
- Claim form
- Available
- Phone
- 866.524.4169
- QCC Insurance Company
- Website
- www.performrx.com/performrx_pdp/
- Formulary
- Available
- Claim form
- N/A
- Phone
- 888-457-3007
- Medco Health Solutions
- Website
- www.yourxplan.com/medco/consumer/medicare/
- Formulary
- N/A
- Claim form
- N/A
- Phone
- 800.758.3605
- Healthnet
- Website
- www.healthnet.com/
- Formulary
- N/A
- Claim form
- Available
- Phone
- 800.903.0944
- Well Mark Inc/Prime Therapeutics
- Website
- www.myrxassistant.com
- Formulary
- Available
- Claim form
- Available
- Phone
- N/A
- Rx America
- Website
- www.rxamerica.com/meds4medicare/
- Formulary
- Available
- Claim form
- Available
- Phone
- 800.429.6686
- PacifiCare (Prescription Solutions)
- Website
- www.prescriptionsolutions.com
- WellCare Health Plans
- Website
- www.wellcarepdp.com
- Formulary
- Available
- Claim form
- N/A
- Phone
- 888.547.5252
- Universal American Financial Corp
- Website
- www.rxpathway.com/
- Formulary
- Available
- Claim form
- Available
- Phone
- 800.766.3233
- Cigna
- Website
- www.cigna.com/health/consumer/medical/cignaturerx/
- Formulary
- Available
- Claim form
- Available
- Phone
- 800.735.1459
- Blue Cross & Blue Shield MI
- Website
- www.bcbsm.com/medicare/formsClaims.shtml
- Formulary
- Available
- Claim form
- N/A
- Phone
- 800.565.1770
- Sierra Rx
- Website
- www.sierrahealthandlife.com
- Formulary
- Available
- Claim form
- Available
- Phone
- N/A
- Wellpoint
- Website
- www.wellpointrx.com
- Formulary
- Available
- Claim form
- N/A
- Phone
- 866.755.2776
- Member Health, Inc./Community Care Rx
- Website
- www.communitycarerx.com
- Formulary
- Available
- Claim form
- N/A
- Phone
- 866.684.5353
- Health Care Service Corporation/Prime Therapeutics
- Website
- www.myrxassistant.com
- Formulary
- Available
- Claim form
- Available
- Phone
- N/A
MA-PDs
- Aetna
- Website
- www.aetnamedicare.com
- Formulary
- Available
- Claim form
- Available
- Phone
- 800.414.2386
- Kaiser Permanente
- Website
- www.kaiserpermanente.org/
- Formulary
- Available
- Claim form
- Available
- Phone
- 800.443.0815
- Highmark
- Website
- www.highmarkbcbs.com
- Formulary
- Available
- Claim form
- N/A
- Phone
- 800.294.9568
- Wellpoint
- Website
- www.bcbsga.com/
- Formulary
- N/A
- Claim form
- N/A
- Phone
- 866.755.2776
- HIP, Health Plan of New York
- Website
- www.hipusa.com/medicare/index.html
- Formulary
- Available
- Claim form
- N/A
- Phone
- 800/447-8255
- MMM Healthcare
- Website
- www.medicareymuchomas.com
- Formulary
- Available
- Claim form
- N/A
- Phone
- 866/333-5470 ext 5406
- Wellcare Healthplans Inc
- Website
- www.wellcare.com/Medicare/Home.aspx
- Formulary
- Available
- Claim form
- Available
- Phone
- 888/423-5252
- Coventry Health Care
- Website
- www.advantrarx.net/jccf/tiles.do?def=plan.druglist
- Formulary
- Available
- Claim form
- N/A
- Phone
- 866/823-5177
- Pacificare
- Website
- www.prescriptionsolutions.com
- Formulary
- Available
- Claim form
- Available
- Phone
- 800/711.4555
- Humana
- Website
- www.humana.com
- HealthNet
- Website
- www.healthnet.com
- Independence Blue Cross
- Website
- www.site65.com
- NewQuest Health Solutions LLC
- Website
- www.myhealthspring.com/
- SCAN Health Plan
- Website
- www.scanhealthplan.com/article/aboutscan/aboutscan.html
- Empire HealthChoice Assurance
- Website
- www.empireblue.com/