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/