We reimburse contracted providers for covered immunization services, including necessary supplies.
- Log in for our Immunizations payment policy and the fee schedule for drugs and vaccines.
You can help members save money
How can you help?
Encourage Medicare members with prescription drug benefits to receive their Part D vaccines at a retail pharmacy and not from a medical provider.
(Note: Medical clinics inside pharmacies, such as MinuteClinic, are considered medical providers, NOT pharmacy providers.)
Why does this save them money?
Part D vaccines are part of the member’s pharmacy benefit—not their medical benefit.
Members who receive Part D vaccines from a medical provider must submit a claim to us to be reimbursed. When a member follows this process, they are reimbursed according to their provider’s allowed amount for the administration of the drug, and this may not cover the total cost to the member.
When a Part D vaccine is administered by a pharmacy, administration costs are covered.
Pharmacy benefits for adult immunizations
Members 18 years of age and older with pharmacy benefits can go to an in-network 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
- COVID-19
- Diphtheria, tetanus, whooping cough
- Flu (see Fact Sheet)
- Hepatitis A
- Hepatitis B
- HPV
- Influenza
- Measles, mumps, rubella
- Meningitis
- Pneumonia
- Polio
- RSV (ages 60 and older, or pregnant women 32 to 36 weeks gestation)
- Shingles (ages 50 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
Medicare Part D coverage
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, all vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) will be $0 copay for Medicare members.
| Part B covers these vaccines | Part D covers these vaccines |
|---|---|
|
Vaccines that are not covered by Part B, such as:
|
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. The features enable healthcare professionals to determine important billing factors, such as:
- Whether a patient has Medicare Part D coverage
- Which Part D plan the facility will need to bill
- What the patient’s financial responsibility is for a specific vaccine and date of service
- How much the physician will be reimbursed
Not enrolled in TransactRx? You'll need to complete a one-time-only registration process and sign an agreement with POC.
- Whether a patient has Medicare Part D coverage
- Bill the member for the vaccine and its administration. The member is then required to submit the claim to us for reimbursement. For help, the member can contact Member Services via the telephone number on their Blue Cross member ID card. Please note that the member may not be reimbursed for the full amount.
- Bill the member for the vaccine administration only. You can obtain the vaccine through a specialty pharmacy provider (contact 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 us for reimbursement of the administration costs. Please note that the member may not be reimbursed for the full amount. A member who is getting a vaccine from a retail pharmacy can avoid the administration costs by having the vaccine administered at the pharmacy.
