Vaccine Coverage

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.

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 minus two things: (1): your normal coinsurance OR copayment for the vaccine (including administration) and (2): any difference between the amount the doctor charges and what we normally pay. (If you get “Extra Help” as defined in your EOC, we will reimburse you for this difference.) You can also find more information about this in Chapter 7 of your EOC.

• Medicare Part D Prescription Claim Form

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 you paid minus two things: (1): any difference between the amount the doctor charges as well as (2): what we normally pay. (If you get “Extra Help” as defined in your EOC, we will reimburse you for this difference.) See examples of what you will pay in our FAQs section below. You can also find more information about this in Chapter 7 of your EOC.

• Medicare Part D Prescription Claim Form

Advantage MD’s reimbursement fee for vaccine administration to all providers is $15.

NOTE: If you pay a copay for your vaccine, then you are reimbursed what you paid for the vaccine administration minus the $15 allowed charge.

Example 1

You pay $42 for a Preferred Brand vaccine at a network pharmacy. You take the vaccine to your doctor for administration, and the doctor charges $15. When you submit your reimbursement claim form to us, you will be reimbursed $15, which covers the cost of the administration in full, leaving you with only the cost of the vaccine itself ($42).

Cost of vaccine from a network pharmacy

You pay: $42

Cost of administration by your doctor

Administration fee: $15 (You pay this at the time of service.)
We reimburse: $15

Your total out of pocket: $42

($42 cost of vaccine + $15 administration fee – $15 reimbursement for administration)

Example 2

You pay $42 for a Preferred Brand vaccine at a network pharmacy. You take the vaccine to your doctor for administration, and the doctor charges $25. When you submit your reimbursement claim form to us, you will be reimbursed $15, which covers a portion of the cost of administration, leaving you to pay the remaining $10 for the administration plus the cost of the vaccine itself ($42). Your total out of pocket cost would be $52.

Cost of vaccine from a network pharmacy

You pay: $42

Cost of administration by your doctor

Administration fee: $25 (You pay this at the time of service.)
We reimburse: $15

Your total out of pocket: $52

($42 cost of vaccine + $25 administration fee – $15 reimbursement fee for administration)

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.

Part D vaccines are listed in your plan’s formulary.

• PPO formulary
• HMO formulary

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 the 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.

• Medicare Part D Prescription Claim Form

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 1-877-293-5325 (TTY: 711) and select option 2.

HMO members: call 1-877-293-4998  (TTY: 711) and select option 2.

See Chapter 7 of your Evidence of Coverage for additional information on the reimbursement process.