CMS updates guidance on Part D vaccines

Wednesday, July 10, 2024

CMS recently updated an MLN Fact Sheet on Medicare Part D vaccines to clarify billing and formulary policies.

Part D plans cover all commercially available vaccines that are reasonable and necessary to prevent illness, except those covered by Part B, according to the fact sheet. CMS clarified that Part D plans may not immediately add newly approved vaccines to their formularies. The agency added that, if a new vaccine is not on the formulary, the enrollee or their representative, prescribing physician, or other prescriber can request coverage through the formulary exception process.

Part D plans also cover the following administration costs as part of a vaccine’s negotiated price:

  • Dispensing fee (if applicable)
  • Vaccine administration fee
  • Vaccine ingredient cost

When the same provider is both dispensing and administering a Part D vaccine, organizations are to use one claim to bill for the vaccine and its associated administration costs, according to CMS. This applies to both in- and out-of-network providers.

Part D plans may pay either a single vaccine administration fee for all vaccines or multiple fees based on the following:

  • Product administration complexity
  • Provider type
  • Vaccine type

The fact sheet also provides instructions to in- and out-of-network pharmacies on how to dispense, administer, and bill Part D vaccines.

Editor’s note: Find more NAHRI resources on vaccine coding and billing here.