Part D Vaccines

SCAN Health Plan® provides coverage of a number of Part D vaccines under our Part D prescription drug benefit. Some covered Part D vaccines include but are not limited to Shingrix or Zostavax® (shingles vaccines) and T-DAP (whooping cough vaccine).

You can find a complete list of the Part D vaccines we cover in our list of covered drugs (Formulary) or click here for more information on which Part D vaccines are available at no cost.

There are two parts to our coverage of Part D vaccinations:

• Cost of the vaccine medication itself
• Cost of giving the vaccine (also called “administration”)

SCAN gives members the choice of receiving their vaccine at the pharmacy or the doctor’s office. What members pay when receiving the Part D vaccination can vary depending on:

• Where members get the vaccine
• Who gives members the vaccine

Note: Members are responsible for all of the costs associated with vaccines (including the administration) during the coverage gap stage of their benefit.

There are four ways members can get a Part D vaccination shot:

Option 1: Members receive the Part D vaccine and administration using retail pharmacy (this is the preferred method):

• Members go to the pharmacy with a prescription for the vaccine.
• The pharmacy fills the prescription and the pharmacist administers the vaccine.
• The pharmacy submits the vaccine claim with the drug cost and administration fee.
• The members are charged a copay for the medication.

Option 2: Members get the Part D vaccination administered at the doctor’s office using TransactRx:

• Members go to the doctor’s office.
• The doctor bills the Part D vaccine and the administration fee online through TransactRx.
• Members pay the pre-calculated copay provided by the online tool.
• The physician dispenses and administers the vaccine.

Note: In order to participate, providers must complete a simple enrollment and agreement process by visiting the TransactRx vaccine manager.

Option 3: Vaccine and administration at the doctor’s office (TransactRx isn’t used):

• Members go to the doctor’s office.
• The doctor dispenses and administers the vaccine.
• Members pay 100 percent out of pocket for the entire cost of the vaccine and its administration.
• The member submits a paper claim to Express Scripts and asks SCAN to pay for its share of the cost.

See below for information about how to submit a Part D vaccine claim for reimbursement. Members will be reimbursed based on the SCAN contracted rate for the vaccine minus the members’ copay and will be reimbursed for the full cost of the administration if that is billed separately. The SCAN contracted rate for the vaccine may be different from the amount the doctor charges (if members get Extra Help, we will reimburse the members for this difference).

Option 4: Members buy the Part D vaccine at a network pharmacy and take it to a doctor’s office where they get the vaccination:

• Members pay the pharmacy the copayment or coinsurance for the vaccine. Members will pay the entire cost of getting the shot at the doctor’s office.
• Members submit the paper claim to Express Scripts for administration fee only.
• If approved, members will be reimbursed the administration fee as submitted (no copay for the administration fee will apply).

For members who choose to receive their Part D vaccine and/or the administration at the doctor’s office, the member must submit the following information with their Part D vaccine claim for reimbursement in writing or through a reimbursement claim form. The form can be found here or contact SCAN Member Services to request a form. If submitting in writing, please include:

• Date of service
• Member name
• Member pharmacy benefit ID
• Drug name and strength
• National drug code
• Quantity dispensed
• Length of supply
• Cost of the drug
• Administration or dispensing fee amount
• Total cost
• Pharmacy name/national provider identifier (NPI) and/or doctor name/NPI

Because both the drug cost and the administration of the Part D vaccine are covered under the Part D prescription drug benefit, members may submit their Part D vaccine claim to:

Express Scripts ATTN:
Medicare Part D P.O. Box
14718 Lexington, KY 40512-4718

Do not submit the claim to the SCAN Claims Department as it will delay the processing of the claim. Members should refer to their Evidence of Coverage booklet for further information.

SCAN Health Plan is an HMO plan with a Medicare contract. Enrollment in SCAN Health plan depends on contract renewal.