How are vaccines covered, and how can I get reimbursed for vaccine administration costs?

Our plan provides coverage of a number of Part D vaccines. There are two parts to our coverage of Part D vaccinations:

  • The first part of coverage is the cost of the vaccine medication itself. The vaccine is a prescription medication.
  • The second part of coverage is for the cost of giving you the vaccination shot. (This is sometimes called the “administration” of the vaccine.)
 
What do you pay for a Part D vaccination?

1. The type of vaccine (what you are being vaccinated for). 

  • Some vaccines are considered medical benefits. Please refer to Chapter 4 of your Evidence of Coverage to find out about your coverage of these vaccines.
  • Other vaccines are considered Part D drugs. You can find these vaccines listed in the plan’s List of Covered Drugs (Formulary). 

2. Where you get the vaccine medication. 

3. Who gives you the vaccination shot. 

What you pay at the time you get the Part D vaccination can vary depending on the circumstances. For example: 
  • Sometimes when you get your vaccination shot, you will have to pay the entire cost for both the vaccine medication and for getting the vaccination 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 vaccination shot, you will pay only your share of the cost. 
 
Remember you are responsible for all of the costs associated with vaccines (including their administration) during the Coverage Gap Stage of your benefit. (BlueCHiP for Medicare Preferred, BlueCHiP for Medicare Group Preferred and BlueCHiP for Medicare Group Preferred Unlimited Plan members: depending on which tier the vaccine is on, you may have coverage for some vaccines during the gap). 
 
Situation 1: You buy the Part D vaccine at the pharmacy and you get your vaccination shot at the network pharmacy. (Whether you have this choice depends on where you live. Some states do not allow pharmacies to administer a vaccination.) 
  • You will have to pay the pharmacy the amount of your coinsurance or copayment for the vaccine itself.
  • Our plan will pay for the cost of giving you the vaccination shot. 
 
Situation 2: You get the Part D vaccination at your doctor’s office. 
  • When you get the vaccination, you will pay for the entire cost of the vaccine and its administration. 
  • You will be reimbursed the amount you paid less your normal coinsurance or copayment for the vaccine (including administration). 
 
Situation 3: You buy the Part D vaccine at your pharmacy, and then take it to your doctor’s office where they give you the vaccination shot. 
  • You will have to pay the pharmacy the amount of your coinsurance or copayment for the vaccine itself. 
  • When your doctor gives you the vaccination shot, you will pay the entire cost for this service.
  • You will be reimbursed the amount charged by the doctor for administering the vaccine. 
 
Please note: Some vaccines are considered medical benefits. You can find out about your coverage of these vaccines by going to Chapter 4, Medical Benefits Chart (what is covered and what you pay) in your Evidence of Coverage.The rules for coverage of vaccinations are complicated. We are here to help. We recommend that you call us first whenever you are planning to get a vaccination. We can tell you about how your vaccination is covered by our plan and explain your share of the cost.
  • We can tell you how to keep your own cost down by using providers and pharmacies in our network.
  • If you are not able to use a network provider and pharmacy, we can tell you what you need to do to get payment from us for our share of the cost.

Last updated: 09/23/2013

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Blue Cross & Blue Shield of Rhode Island is an HMO plan with a Medicare contract. Enrollment in Blue Cross & Blue Shield of Rhode Island depends on contract renewal.