Reimbursement FAQs: Vaccines

As an independent pharmacy, I would like to provide vaccines for my customers, but the overhead risks are too high. Is there a way to avoid these risks?

Yes. A pharmacy operator’s best solution is to work with a vaccine provider that can remove the risks associated with vaccination, such as purchasing expensive products and storing them in inventory until they are used. Some vaccine providers allow the consumer to register online to receive a vaccine and then will send the vaccine specific for that consumer to the pharmacy “just in time” for administration. A vaccine provider also will provide billing services and pay the pharmacy to perform the administration. This type of partnership allows independent pharmacies to provide vaccination services to their community without taking costly overhead risks.

Medicare Part B covers 100 percent of the cost for some seniors’ vaccines. How well is this benefit used?

According to the Centers for Medicare and Medicaid Services (CMS), pneumonia and influenza are the eighth leading cause of deaths in older adults. Medicare Part B pays for one influenza vaccine each year with no copayment or deductible applied. Medicare generally pays for one pneumonia vaccination for all Medicare beneficiaries per lifetime. However, if a beneficiary is considered high risk, a booster may be given and also is covered in full.

Despite full coverage for these vaccines, rates of immunization in the senior population remain suboptimal, particularly in minority populations. This may be due in part to lack of education about Medicare benefits. Moreover, from a reimbursement viewpoint, the problem is likely due to access issues on multiple levels.

For instance, providers are unable to bill Medicare for an office visit when the only reason for the visit is a vaccine. If the office visit is for a medical reason covered under Medicare, the vaccine given in conjunction with that visit will be covered. Consequently, seniors simply needing a vaccine may put off vaccination until they have another reason to visit their physician. In addition, some Medicare Advantage plans limit the number of contracted providers for their Medicare members, thus eliminating some of the more convenient vaccine locations such as supermarket pharmacies.

To learn more about provider resources for vaccines, go to www.cms.gov/Adult Immunizations/02_Provider resources. asp.

Is Gardasil covered by insurance?

Insurance companies are more likely to cover vaccines that the Centers for Disease Control and Prevention (CDC) recommend. HPV vaccines, such as Gardasil, are recommended by the CDC for both females and males.

How do insurers reimburse for vaccines?

Insurers often see the value of vaccines, and many provide vaccine coverage. Depending on the insurer, vaccines may be covered under the wellness benefit, major medical or the prescription plan. Wellness benefits generally cover 100 percent of the vaccine with no out-of-pocket expense for the patient.

However, vaccines may be subject to copayments and deductibles in some plans. For some providers, the cost of filing reimbursement claims outweighs the benefits. In this case, filing for reimbursement may be left up to the patient. Recently passed healthcare reform may change how vaccines are covered by January 2011.

According to the Kaiser Family Foundation’s Summary of Health Reform, plans will be required to provide, at a minimum, coverage without cost-sharing for preventive services rated A or B by the U.S. Preventive Services Task Force (USPSTF). This reform would include vaccines.

As a specialty pharmacy, we would like to expand our services to offer flu vaccine clinics for employer groups. Targeting large employers seems to make the most business sense for us. However, most large employers already contribute to their employees’ health insurance, which usually covers vaccines. Why, then, would these employers be willing to fund and host a vaccine clinic if vaccines are already a covered insurance benefit?

According to the U.S. Chamber of Commerce, flu outbreaks cost the U.S. economy $10 billion in lost productivity and medical expenses annually. Working to reduce these costs, employer-sponsored workplace flu clinics have proven to keep employees healthy and working. Vaccinations not only decrease the loss of productivity related to absenteeism, but workers protected by vaccination decrease the risk of infecting co-workers, halting the potential spread of disease. Because workplace flu shot clinics are so quick and easy, they can be held during any shift and are completed in as little as five to 10 minutes per employee. Providing quick, convenient vaccine access to employees boosts the rate of vaccination in the workplace, decreases the risk of infection, and thereby supports productivity and, ultimately, profits, always key concerns for employers. To learn more about employer-sponsored vaccination clinics, go to www.VaxAmerica.com.