Vaccine coverage to be available under the pharmacy benefit

Effective in 2020, upon a client’s next renewal, coverage of vaccines will be available under the pharmacy benefit. Previously, vaccines were typically available only through the medical benefit. In the past, only certain pharmacies, mostly chains, could administer vaccines under the medical benefit. Now, vaccine coverage, if administered by a certified pharmacist, will be available through our network of retail pharmacy providers. Customers can simply visit an in-network pharmacy, show their prescription ID card, and request a flu shot or other covered vaccine. The pharmacy will then be responsible to submit the vaccine for billing via the pharmacy benefit.

Vaccines available for coverage include flu, tetanus/diphtheria/pertussis, hepatitis, human papillomavirus (HPV), meningitis, pneumonia, shingles/zoster, and childhood vaccines such as measles, mumps, rubella (MMR).

Covering eligible vaccines through the pharmacy benefit is just one more way to make access to care a bit simpler. Customers and their covered dependents will have the convenience of using a local pharmacy to obtain needed vaccines.

All states allow certified registered pharmacists to administer flu and shingles vaccines. And most states allow pharmacists to administer all other vaccines.* However, every state has specific regulations regarding age restrictions, which vaccines can be administered by a certified pharmacist, and if a prescription is required. Customers can contact their network pharmacy in advance to check on vaccine availability, whether a certified pharmacist is available to administer the needed vaccine, hours of operation, age restrictions, etc. Mini-clinics within retail pharmacy stores are NOT part of this program because they can only process the claim through the medical benefit.

Coverage will include claim payment for the vaccine drug product and pharmacist administration of the vaccine. This coverage is only available through pharmacy providers as a service administered by duly certified pharmacists. The pharmacy coverage cannot extend to other types of medical providers or pharmacy-based health clinics.

*State regulations apply. Which vaccines pharmacists can administer, patient age restrictions, and prescription requirements vary by state.

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Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a licensed pharmacy and medically necessary. Some plans require you to use an in-network pharmacy for prescriptions to be covered. Coverage is subject to any plan deductible, copayment and/or coinsurance requirements. Product availability may vary by location and plan type and is subject to change. All group health insurance policies and health benefit plans contain exclusions and limitations. For costs and details of coverage, contact a Cigna representative. Group medical and pharmacy plans are insured and/or administered by Cigna Health and Life Insurance Company or its affiliates. Policy forms: OK - HP-APP-1 et al., OR - HP-POL38 02-13, TN - HP-POL43/HC-CER1V1 et al. All pictures are used for illustrative purposes only. This website is not intended for residents of New Mexico.

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