Vaccine Coverage
Resources on This Page
- PPO formulary – English | Spanish
- HMO formulary
- HMO D-SNP formulary – English | Spanish
About Your Part D Vaccine Coverage
Getting the vaccinations you need is important for your best health. Getting vaccines administered at the right location is important for your best coverage. Learn about your vaccine coverage, administration options, and what you should expect to pay below.
We understand the rules for coverage of vaccinations are complicated. That’s why we are here to help. Call Customer Service when you are planning to get a vaccination.
PPO members: call 877-293-5325 (TTY: 711) and select option 2.
HMO members: call 877-293-4998 (TTY: 711) and select option 2.
We are available 24 hours a day, seven days a week.
Two Parts to Vaccination Coverage
Advantage MD provides coverage for a number of Part D vaccines:
- The first part of coverage is the cost of the vaccine itself. A vaccine is a prescription medication.
- The second part of coverage is the cost of your provider giving you the vaccination shot. (This is called the “administration” of the vaccine.)
What You Pay Depends on 3 Things
What you pay at the time when you get a Part D vaccination varies depending on the circumstance. Sometimes when you get your vaccine, you will have to pay the entire cost for both the vaccine medication and for getting the vaccine shot. You can ask our plan to pay you back for our share of the cost. Other times, when you get the vaccine medication or the vaccine, you will pay only your share of the cost.
1. The type of vaccination
Some vaccines are considered Part D drugs. You can find these vaccines listed in the formulary. Other vaccines are considered Part B medical benefits. You can read how these vaccines are covered in the Medical Benefits Chart in Chapter 4 of your Evidence of Coverage (EOC).
2. Where you get the vaccine medication
Vaccine medications could be purchased from a pharmacy or from your doctor’s office.
3. Who gives you the vaccine
You could have the pharmacist (if applicable) or your provider administer your shot.
Three Options to Get Your Vaccine
You buy the Part D vaccine at the pharmacy and you get your vaccination administered at the pharmacy.Collapse
This option depends on the pharmacy. Some pharmacies do not administer vaccines so you’ll want to check with yours in advance to make sure they can provide the vaccination. You will have to pay the pharmacy the amount of your coinsurance or copayment for the vaccine and its administration. Our plan will pay the remainder of the costs.
You get the Part D vaccine and the vaccination shot at your doctor’s office.Collapse
When you get the vaccination, you will pay for the entire cost of the vaccine and its administration. You can then request reimbursement for the plan’s share of the cost by filling out a Medicare Part D prescription claim form and following our reimbursement procedure outlined in the FAQs below. You will be reimbursed the amount you paid less your normal coinsurance or copayment for the vaccine (including administration). You can also find more information about this in Chapter 6 of your EOC.
You buy the Part D vaccine at your pharmacy and then take it to your doctor’s office where you get the vaccination.Collapse
You will have to pay the pharmacy your coinsurance OR copayment for the vaccine itself. When your doctor gives you the vaccination, you will pay the entire cost for this service. You can then request reimbursement for the plan’s share of the cost by filling out a Medicare Part D prescription claim form and following our reimbursement procedure outlined in the FAQs below. You will be reimbursed the amount charged by the doctor for administering the vaccine. See examples of what you will pay in our FAQs section below. You can also find more information about this in Chapter 6 of your EOC.
FAQs
Are all vaccines covered under Part D?Collapse
No, the following vaccines and their administrations are covered under your Advantage MD Part B medical benefit:
- Influenza
- Pneumococcal
Part B vaccines are available from your provider’s office or a network pharmacy. Show the pharmacist your Advantage MD card to receive these vaccinations at no cost to you.
How do I know which vaccines are covered by Part D?Collapse
Part D vaccines are listed in your plan’s formulary.
- PPO formulary – English | Spanish
- HMO formulary
- HMO D-SNP formulary – English | Spanish
How do I get reimbursed for vaccines?Collapse
Sometimes when you get a vaccine and/or the shot at a non-network pharmacy or at the physician’s office, you may need to pay the full cost right away. Other times, you may find that you have paid more than expected under the coverage rules of the plan. In either case, you can ask our plan to pay you back (reimburse).
To speed up the reimbursement process and to make sure that you are giving us all the information we need, you should complete the Medicare Part D Prescription Claim Form and send this form along with a detailed receipt for the vaccine and the pharmacy label, or your pharmacy prescription claim history to us. (The pharmacy label is generally attached to your prescription bag when you pick up your medication and includes the name of the drug, quantity, date of purchase, and cost of the drug. Your pharmacy prescription claim history is a print out of what prescription you filled and paid for.)
You do not have to use the Medicare Part D Prescription claim form, but the use of this form will speed up the reimbursement process.
Please mail your request for payment together with any receipts to:
Johns Hopkins Advantage MD
c/o CVS/caremark Part D Services
PO BOX 52066
Phoenix, AZ 85072-2066
If you have any questions, you can call Customer Service 24 hours a day, seven days a week.
PPO members: call 877-293-5325 (TTY: 711) and select option 2.
HMO members: call 877-293-4998 (TTY: 711) and select option 2.
See Chapter 7 of your Evidence of Coverage for additional information on the reimbursement process.
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