Pharmacies administering COVID-19 vaccine boosters or primary series doses to Medicare patients need to know of a significant change to the billing process. Patients who have a standalone prescription drug plan will still be paid by Part B fee-for-service. All other Medicare patients (e.g., Medicare Advantage plans, MAPDs) will be covered by the managed care plan which may cover the administration fee on the pharmacy benefit, medical benefit, or both. CMS allows these managed care plans to deny payment to out-of-network providers unless the plan has an out-of-network benefit. For information on determining the plan type or on submitting denied claims to the Coverage Assistance Fund (NOT the HRSA Uninsured Program), read the updates to NCPA’s COVID-19 vaccine billing handout.
NCPA
