Members 18 years of age and older with pharmacy benefits can go to a participating Express Scripts retail pharmacy to get the vaccinations listed below. These are covered with no cost share to the member and a prescription is not required.
The pharmacist must be registered and licensed to administer these vaccines:
- Chicken pox
- Diphtheria, tetanus, whooping cough
- Hepatitis A
- Hepatitis B
- Measles, mumps, rubella
- Shingles (ages 60 and older only)
This benefit applies to members who have pharmacy benefits and participate in these plans:
- Commercial HMO, PPO, POS, and Access Blue
- Medicare Supplemental plans, including Medex and Managed Blue for Seniors
Some vaccines administered to Medicare beneficiaries are covered under Part B; most others are covered under Part D (see chart below for examples).
For vaccines administered under Part D, reimbursement includes the vaccine ingredient cost, dispensing fee, and administration. This means that Medicare members can only be charged one pharmacy copayment for both the vaccine and for its administration.
|Part B Covers These Vaccines:
||Part D Covers These Vaccines:
- Hepatitis B for intermediate to high-risk beneficiaries
- Any medically necessary vaccines used to treat illness or injury
Those vaccines that are not covered by Part B, such as:
- Herpes zoster (Zostavax®′)
- Hepatitis B
You have three options for submitting claims for vaccines that you administer to Medicare Advantage members with prescription drug benefits (Part D):
- Use TransactRx. This web-based tool, offered by POC Technologies, lets you submit claims electronically to our Pharmacy Benefit Manager, Express Scripts, Inc. (ESI), and to:
- Verify member eligibility, benefits, and reimbursement information in real-time
- Advise members of their appropriate out-of-pocket expense. ESI tracks all vaccine costs and administration fees that count towards the member’s benefit (True Out of Pocket [TrOOP] and Total Drug Spend).
Not enrolled? You'll need to complete a one-time-only registration process and sign an agreement with POC.
- Bill the member for the vaccine and its administration. The member is required to submit the claim to BCBSMA for reimbursement. For help, the member can contact Member Services via the telephone number on their BCBSMA ID card.
- Bill the member for the vaccine administration only. You can obtain the vaccine through a specialty pharmacy provider (contact Clinical Pharmacy Operations at 1-800-366-7778 for a list of specialty pharmacies) and charge the member for the vaccine administration. Or, the member, using a prescription obtained from a physician, may obtain the vaccine from a retail pharmacy and bring it to you for administration. This option requires the member to submit the claim to BCBSMA for reimbursement of the administration costs.