Covered and Noncovered Services : Covered Services and Requirements

Vaccines

General Information

Pharmacy providers may administer all vaccines that are approved by the CDC and recommended by ACIP to BadgerCare Plus and Medicaid members and SeniorCare members.

ForwardHealth does not cover vaccines when they are not approved by the CDC and when they are not recommended by ACIP. ForwardHealth does not require PA for vaccines, and there is no out-of-pocket expense to the member.

Per Wis. Stat. § 450.035(2i) pharmacy providers may administer any ACIP-recommended vaccine without a prescription when the vaccine is listed on the current immunization schedules recommended by ACIP and published by the CDC.

Pharmacy providers are required to submit a professional claim for vaccines administered to ForwardHealth members for reimbursement. Claims for vaccine administration submitted on compound or noncompound drug claims using NDCs will be denied.

Tracking Vaccines in the Wisconsin Immunization Registry

Per Wis. Stat. § 450.035(4), pharmacy providers are required to enter administered vaccines for all members into the WIR within seven days of administering the vaccine.

Vaccines Provided to Children

Pharmacy providers may obtain vaccines at no cost to provide to members 18 years of age and younger through the federal VFC program.

Therefore, ForwardHealth will only reimburse the administration fee for vaccines provided to BadgerCare Plus and Medicaid members 18 years of age and younger.

In order to receive vaccines at no cost, providers are required to enroll in the VFC Program.

Note: To receive vaccines through the VFC program for the annual influenza season, providers are required to be enrolled in the VFC program and place orders no later than February of that year.

Per 2015 Wisconsin Act 55, trained pharmacy providers who enroll in the federal VFC program are authorized to receive reimbursement from ForwardHealth. In general, all CDC-approved and ACIP-recommended vaccines for children are available through the VFC program at no cost to providers. ForwardHealth will only reimburse for the administration of the vaccine for BadgerCare Plus and Medicaid members 18 years of age and younger.

ForwardHealth does not publish best practice standards for vaccines provided to children. Pharmacy providers are responsible for keeping up to date on vaccine best practice standards, including immunization schedules, dosages, and contraindications as published by the CDC.

Provider Participation Requirements

Medicaid-enrolled pharmacies are required to meet the following requirements to be reimbursed for administering vaccines to children:

• The pharmacy is required to enroll in the VFC program and comply with the requirements of the program.
• The pharmacy provider administering the vaccine is required to have the authority and training to administer vaccines to children per the requirements of the Pharmacy Examining Board under Wis. Stat. ch. 450.

Vaccines Provided to Adults

For vaccines administered to BadgerCare Plus and Medicaid members (19 years of age or older), pharmacy providers are required to use vaccines from their private stock. ForwardHealth reimburses pharmacy providers for both the vaccine and the administration of the vaccine.

Vaccines Provided to SeniorCare Members

SeniorCare members may only receive covered vaccines through a ForwardHealth-enrolled pharmacy. Vaccines are not covered by SeniorCare when provided at any location other than a ForwardHealth-enrolled pharmacy.

Allowable Procedure Codes

Pharmacy providers are required to indicate the CPT procedure code of the actual vaccine administered, not the administration code, on professional claims for all vaccines administered. Pharmacy providers should not separately bill the administration code because reimbursement for administration is incorporated into vaccine reimbursement.

The most current list of allowable procedure codes for vaccines administered is in the service-specific interactive maximum allowable fee schedules.

Claim Submission

Wisconsin Medicaid and BadgerCare Plus fee-for-service reimburses pharmacy providers for vaccine services for both children (18 years of age and younger) and adult members even if the member is enrolled in a state-contracted MCO. This exception applies to pharmacy providers only. SeniorCare reimburses pharmacy providers for vaccines administered.

Pharmacy providers may submit professional claims for vaccine administered for BadgerCare Plus, Medicaid, and SeniorCare members via the following:

• The 1500 Health Insurance Claim Form
• The 837P electronic transaction
• DDE on the ForwardHealth Portal
• PES claims submission software

Pharmacy providers may not submit compound or noncompound drug claims for vaccines administered using NDCs. Compound or noncompound drug claims submitted with NDCs for vaccines administered will be denied.

If a member is enrolled in a BadgerCare Plus HMO, pharmacy providers are required to submit claims to Wisconsin fee-for-service Medicaid. BadgerCare Plus HMOs are not able to accept claims from pharmacy providers.

Claim Submission Information for SeniorCare

SeniorCare is the payer of last resort. Pharmacy providers are required to bill the member's other health insurance and Medicare plans before submitting claims to ForwardHealth. When a member has a Medicare Part B or Part D plan, pharmacy providers should first submit a claim to the Medicare Part B or Part D plan. Once a response is received from the Medicare plan, pharmacy providers may submit a claim to ForwardHealth for reimbursement. Pharmacy providers should include all relevant information form the Medicare plan, (for example, coinsurance, deductible, or copay) in order to coordinate benefits.