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Medicare/WellCare Part B versus Part D Vaccines

July 6, 2009

Coverage for the Medicare Prescription Drug Benefit, referred to as Medicare Part D, began on January 1, 2006. CMS revised payment policies for the provision and administration of Part D-covered vaccines furnished to Medicare-eligible enrollees in January of 2007 and 2008, with a minor revision in May 2009, creating greater complexity to vaccine billing. There are currently over 20 preventive vaccines covered under Medicare Part D, with several vaccines remaining under Part B. This has created confusion in Physicians offices related to who to bill and how to bill for these vaccines. This article presents some updated information and general guidelines on Part B vs. Part D vaccine coverage issues in 2009 for Medicare-eligible beneficiaries.

For WellCare/Medicare members:
Medicare Part B currently covers the following immunizations:
Pneumococcal/pneumonia vaccine;
Influenza virus vaccine;
Hepatitis B vaccine when used to treat individuals at high or immediate risk; and
Other vaccines, such as tetanus toxoid, when directly related to the treatment of an acute injury or direct exposure to a disease or condition.

If the required vaccine is not among those listed above, it is a Part D vaccine. The Part D program generally covers those vaccines not available under Part B; however, unlike Part B, the immunizer may or may not be able to directly bill the Part D sponsor for the vaccine and its administration, but instead may need to work with the beneficiary and his/her Part D plan to facilitate reimbursement.

Several options exist for obtaining vaccines for WellCare members under Part D. These include sending the patient to a Pharmacy, such as Thrif-T Drugs, with a prescription for the medication, then administering the medication in the office; requesting overnight delivery of the vaccine from the WellCare Pharmacy ( an example is the Zostavax vaccine which can be sent overnight in a "cold pack"); having the member pay for the vaccine, then file a "WellCare Direct Member Reimbursement Form" to the WellCare Reimbursement Department; or using another option - the on-line eDispense Vaccine Manager. WellCare is a participating health plan with the eDispense Vaccine Manager program.

There is no cost to the physician to enroll or to process claims through eDispense Vaccine Manager. The 20+ preventative vaccines now covered under Medicare Part D, including Zostavax, Menactra, Menomune, Vaqta, Zostavax, Adacel, Devac, Havrix, etc., can be billed directly to WellCare through this program. EDispense offers on-line, real time, patient co-pay amounts, office reimbursement or product replacement. Marketing information for Vaccine Manager indicates it can look up any Medicare Member's Part D insurance plan and then verify the covered amount for administered vaccines with contracted plans, and can provide a clean and legible paper claim form for other Medic

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