For the holiday season, my family’s gift from my niece was an elaborate & creative show revealing the fact that she was expecting - balloons and all! Since then, I’ve checked all of my medical records to ensure I’m up-to-date with my vaccines, as this aunt plans on having some serious snuggle time with that little angel! Upon my review, I realized that I haven’t taken the measures to prevent Whooping Cough-recently in my area, somewhat of a problem. While I’m scheduled for the combination shot, which is TDAP, I wanted to pass along some information.
Whooping cough, or pertussis, can be a serious disease for people of all ages but especially for babies. This disease can cause infants to get pneumonia, stop breathing, or even become fatal. If you’ve got a newborn in your family-or if you’re expecting one soon- it’s highly recommended by the CDC to get the TDAP Vaccine (tetanus, diphtheria, and pertussis) if you haven’t had one. In most cases it will be covered by your Part D plan.
The amount you pay for your vaccine may vary depending on where you get vaccinated. Be sure to check your plan’s coverage rules and see where you can get your vaccine at the lowest cost. Typically, you will pay the least for your vaccinations at:
A doctor’s office that
coordinates with a pharmacy to bill your Part D plan for the entire cost of the vaccination process (the drug and its injection)
or, can bill your plan directly for the vaccination process using an electronic billing system
When you are vaccinated in either of the above settings, you should only need to pay the plan’s approved coinsurance or copay for the drug and vaccination process. When you get a vaccine at your doctor’s office, ask the provider to call your Part D plan first to find out if your provider can bill your Part D plan directly. If this is possible, you should not have to pay the full out-of-pocket cost and later request reimbursement from your plan.
You may end up paying more for your vaccination if your provider:
cannot coordinate with a pharmacy to bill your Part D plan for the entire cost of the vaccination process (the drug and its injection)
and/or, cannot bill your plan directly for the vaccination process using an electronic billing system
In these circumstances, your provider will bill you for the entire cost of the vaccination (the drug and its injection). You will have to pay the entire bill up front and request reimbursement from your Part D plan. It is important to know that your provider may charge you more than the Part D approved amount for the vaccination, but your plan will only reimburse up to the approved amount—and you will not be refunded for any amount you pay the provider above the Part D approved amount.
If you have Extra Help(Low-Income Subsidy), you can go to any provider or in-network pharmacy to get vaccines. You will be covered for your vaccination and will only be responsible for the Extra Help copay. However, if you get your vaccine from a provider who does not directly bill your plan, you may need to pay the entire bill up front and then request reimbursement from your plan.
Please verify your options with your current plan provider, or your agent before scheduling any shots.
Randall J. Lawson
The HgO Group
National Producer Number #9276045
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