Medicare Part D Vaccine and Administration (Injection) Claim Form

Providers who administer certain vaccines to their Medicare patients may receive payment under the Medicare Prescription Drug (Part D) program. Medicare Part B covers most of the vaccines that Medicare patients need. However, vaccines not covered under Part B are generally covered under Part D. Please consult the formulary for more information on coverage of specific vaccines. For more information about Medicare Part D Vaccine and Administration Payments, please see the Centers for Medicare & Medicaid Services brochure below.

Access options for Virginia Premier CompleteCare:

  1. In-Network Pharmacy Administers the Vaccine

    Patients receive a prescription from the physician and the vaccine is administered by a certified pharmacist at a local, in-network pharmacy (unless prohibited by law). The pharmacy bills Virginia Premier CompleteCare, and the patient pays the pharmacy any required prescription copay amount.

  2. In-Network Physician Administers the Vaccine (Reimbursement Form to be Submitted by Physician)

    Physician obtains vaccine and administers it to the patient. In this case, the physician would initially be responsible for cost(s) associated with obtaining and administering the vaccine. The physician would then submit a claim (see form below) for reimbursement of covered Part D vaccines and their administration.

    Providers seeking reimbursement of covered Part D vaccines and their administration (injection) should complete the form below.