The Point Issue 3 2019

Costs Vary for Vaccines in Office Setting vs. Pharmacy

Guide Your Patients to the Best Location

Did you know that administering some vaccines in your office setting can result in more than an ouch to your patients’ arms? Patients who receive Medicare Part D-covered vaccines in your office can feel the pain in their wallets, too.
Vaccine coverage is available through Medicare Part B (Medical Benefit) and Medicare Part D (Prescription Drug Benefit). For patients covered under both, it’s important for providers and patients to understand that coverage and costs for vaccines can vary greatly based on the location (provider office vs. pharmacy) where they are administered.
Bottom line: Generations Advantage members will always save money when they get their PART D (preventive) vaccines at a pharmacy. This is because Part D vaccines administered outside of a pharmacy are considered out of network. Members may choose to receive Part D vaccines at their prescriber’s office; however, they may not be aware that they may be liable for the out-of-network cost share. We take measures to educate our members about these potential costs and hope that you'll partner with us to further this education and steer your patients to a pharmacy for all their Part D vaccines.
Below is an overview of Medicare vaccine coverage that can help you guide your patients to receive their vaccines in the most cost-effective setting:
ONLY MEDICARE PART B (Medical Benefit) covers the following vaccines:
These vaccines are covered when administered in the provider’s office.

  • Influenza
  • Pneumococcal
  • Hepatitis B for people with high risk factors, such as:
    • End stage renal disease patients
    • Hemophiliacs who receive Factor VIII or IX concentrates
    • Clients of institutions for those with mental retardation
    • Persons who live in the same household as a Hepatitis B Virus (HBV) carrier
    • Homosexual men
    • Illicit injectable drug abusers
    • Persons diagnosed with diabetes mellitus
  • Certain vaccines when administered for TREATMENT of an injury or direct exposure to a disease or condition (see section III below).

ONLY MEDICARE PART D (Prescription Drug Benefit) covers the following vaccines:

These vaccines are covered when administered at a pharmacy. Not fully covered (out of network) when administered in a provider's office.

  • Shingles (Shingrix®/Zostavax®)
  • MMR (Measles, Mumps, and Rubella)
  • Varicella (Chickenpox)
  • Generally, Medicare Part D prescription drug benefits cover all commercially available vaccines needed to PREVENT illness (see section III below). 

COVERED UNDER PART B (in office setting) when TREATING an injury;

  • Tdap (Tetanus, diphtheria and pertussis)
  • Td (booster vaccine for tetanus and diphtheria)

Will completing a prior authorization allow a member to receive the Part D vaccinations in the provider’s office for the same cost as at the pharmacy?

  • A member should always be advised to call their insurance carrier to determine coverage prior to receiving the vaccine.
  • An approved prior authorization may reduce the cost of the vaccine in the office, but it is not guaranteed. The cost to receive Part D vaccines will always be lower at a pharmacy.
  • Members getting their TDAP and Td vaccines at a pharmacy will need a prior authorization to confirm that it is covered under Part D (preventive).

Can a member submit for reimbursement after receiving their bill for a Part D vaccination they received at the prescriber’s office?

  • A member should always call their insurance carrier to determine coverage prior to receiving the vaccine.
  • A member may submit for reimbursement; however, it is not guaranteed that the cost will be reduced once submitted.

How do I assist my patients in getting their vaccines in the most cost-effective way?

  • Be aware of the potential cost differences and share that information with your patients.
  • Guide patients to receive their Part D vaccines at a pharmacy.
  • Provide a written prescription for your patients to take to a pharmacy to receive their Part D vaccines.

HEDIS TRC Time Savers!

Tips for Complete Documentation Submissions

CMS has developed multiple transitions-of-care quality measures for providers and payors to help reduce hand-off-related harms and hospital readmissions. Supporting this effort, Martin’s Point collects data pertinent to the Health Effectiveness Data Information Set (HEDIS) measure called Transitions of Care (TRC). The TRC measure monitors the performance of health plan networks around transitions of care, with an emphasis on notification of admission and discharge to the primary care provider and timely follow up with medication reconciliation.

Due to the lack of interoperability among EMRs, the manual collection and review of EMR and faxed records to determine TRC, compliance can be a painstaking process—both for our reviewers and your office staff who field our record requests. Hopefully, increased understanding of the measure requirements will simplify the process for all involved.

The TRC measure focuses on four primary data points. These are outlined below, along with the documented evidence required to demonstrate HEDIS compliance:

As partners in the continual improvement in patient care, we hope you find this information useful. We look forward to smoother and less frequent communication in HEDIS seasons to come.

“Hold Harmless” Guidelines for Martin’s Point Health Plans

Covered services: Generations Advantage and/or US Family Health —Network providers have contractually agreed that, except for the collection of copayments, coinsurance, deductibles, payments for noncovered services, or payments for covered services provided after their agreement is terminated, in no event shall they bill, charge, collect a deposit from, or seek any recourse against any member or person acting on a member's behalf for covered services.

Noncovered services:
Generations Advantage—Members of our Generations Advantage plan can’t be billed for a noncovered service unless proper notice has been provided in advance. More information on our Generations Advantage Acknowledgement and Financial Responsibility Policy can be found at

US Family Health Plan—Contracted providers must obtain a signed Acknowledgement of Financial Responsibility Statement from the member in order to bill or collect for noncovered surgeries or TRICARE®-excluded services. General waiver forms signed at time of admission are not sufficient per TRICARE regulations. The waiver must be specific to the date of service and include the CPT code and the charge for the service.

For more detailed information about our “Hold Harmless” policy—including procedures and forms for charging members for noncovered services with specific provisions determined by CMS and TRICARE®, visit

Provider Portal Guide

Are you new to our provider portal? Click here to review our Provider Portal Guide.

For assistance with registering for the portal click here to review the User Registration Guide.

Update Your Info Online with Provider DataPoint

CMS now requires us to contact our network providers on a regular basis to confirm that our directory information is up to date. We kindly request that you provide us with thirty (30) days advance notice of any changes to your provider/practice information whenever possible. Also, watch for reminders in future editions of The Point to notify us of any changes to your provider/practice information.

Provider DataPoint is our web-based provider data management tool that helps us maintain accurate provider directories and perform timely and efficient claim processing. Using this tool is an easy way to keep all your practice/provider information up to date and accurate.

PLEASE NOTE: We no longer accept updates, changes, and credentialing applications via email or fax. Please also note that radiologists, anesthesiologists, and midlevel providers (NP, PA) who do not practice as PCPs do not require credentialing.

Please use Provider DataPoint to:

  • Change your practice information, including name, phone/fax, address, billing information, NPI, etc.
  • Add or delete a location to your already-contracted practice/group
  • Change provider information, including name, specialty, panel status, add a language, etc.
  • Add a provider who requires credentialing to your practice
  • Terminate a provider from your practice/group
  • Check the status of a previously submitted data change request

To access Provider DataPoint, visit: Update Your Info
If you have any questions, please see the instructions on our website or speak to a Provider Representative.

Just for Kids

To assure our youngest health plan members receive quality care, Martin’s Point measures:

  • Well-Child Visits in the First 15 Months of Life (W15): A count of the number of well-child visits that occur on or before the child turns 15 months of age.
  • Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34): Children from 3 through 6 years of age have one or more well-child visit(s) during the past year.
  • Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC): Children from 3 through 17 years of age have an outpatient visit in the past year and the following are assessed.
    • BMI—Documentation of a height, weight, and distinct BMI percentile (BMI ranges and thresholds are not acceptable)
    • Nutrition—Documentation of nutrition being addressed (e.g., discussion of behaviors, referrals for nutrition education, providing educational materials, anticipatory guidance, or counseling for weight or obesity)
    • Physical Activity—Documentation of physical activity being addressed (e.g., discussion of behaviors, referrals for physical activity, providing educational materials, anticipatory guidance, or counseling for weight or obesity)
  • Adolescent Well-Care Visits (AWC): Adolescents from 12 through 21 years of age have at least one comprehensive well-care visit during the past year.

Two common diagnoses involving possible prescribing of antibiotics in pediatric patients are pharyngitis and upper respiratory infection. The CDC offers antibiotic-prescribing guidelines that help establish standards of care, focus quality improvement efforts, and improve patient outcomes.

To assure our youngest health plan members receive quality care, Martin’s Point uses these CDC-recommended, evidence-based criteria to assess if your pediatric patient has received appropriate care.

Pharyngitis: Antibiotics? Test for Strep!
The CDC recommends that children prescribed an antibiotic for pharyngitis receive a group A strep test to discriminate between bacterial and viral pharyngitis.
Martin’s Point annually reviews a random sample of claims of children aged 3-18 years who were diagnosed with pharyngitis and dispensed an antibiotic. If a group A strep test was not completed the record fails CDC recommendations and is noted as noncompliant. 

Upper Respiratory Infection (URI): Avoid Treatment with Antibiotics!
The common cold or nonspecific upper respiratory tract infection (URI) can be caused by at least 200 viruses. URI management should focus on symptomatic relief and antibiotics should not be prescribed for these conditions, according to the CDC Pediatric Treatment Recommendations.1

Martin’s Point annually reviews a random sample of claims of children 3-18 years of age who were diagnosed with upper respiratory infection (URI). If an antibiotic was prescribed, the record fails CDC recommendations and is noted as noncompliant.

We appreciate your efforts to follow these guidelines and provide the best, and most appropriate, care for our members and your patients.

ECHO FAST FACTS: Financial Help for Active-Duty Family Members with Special Needs
TRICARE Extended Care Health Option (ECHO) provides active-duty military families with financial help for beneficiaries who are diagnosed with moderate to severe intellectual disability, physical disabilities, or extraordinary physical or psychological disorders.

Members who qualify for ECHO are provided up to $36,000 per year to support services not covered by the basic TRICARE military health care program.
To be eligible for ECHO, military sponsors must be active duty, enroll in the Exceptional Family Member Program (EFMP) and register for ECHO with their regional contractor.
ECHO specialists in the Martin’s Point Health Management department help beneficiaries with enrolling in ECHO, getting access to care, locating providers, and using their benefit. Martin’s Point currently has 20 active enrolled ECHO members and we continue to expand our resources to support the needs of our members.
The Comprehensive Autism Care Demonstration covers applied behavior analysis (ABA) services for children with autism. To received ABA therapy, the member must enroll in the Exceptional Family Member Program (EFMP) and register in the Extended Care Health Option (ECHO).
To be covered by the ECHO program, all programs and supplies must be evidence based and all services require an authorization. One common request for ECHO members is for weighted blankets. At this time, weighted blankets are not a covered benefit.
For questions about ECHO at Martin’s Point Health Care, contact our Health Management department at 877-659-2403.