November 26, 2007 Volume 69 | Number 048 | page 33

Major Part D Plans Turn To Web-Based Vaccine Claims System For Zostavax

A number of large Medicare Part D plan sponsors have contracted to use a Web-basedclaims submission system for coverage of Merck's shingles vaccine Zostavax and other physician-administered vaccines covered by Part D.
Developed by Santa Ana, Calif.-based Dispensing Solutions Inc., the system is called eDispense Vaccine Manager and is targeted specifically to the Medicare market. DSI also offers eDispense point of care programs for physicians in the commercial space.

Leading Part D players that have signed up with eDispense Vaccine Manager include Humana Member Health and Prime Therapeutics, a pharmacy benefit manager affiliated with a number of Blue Cross and Blue Shield plans.
Humana is the second largest sponsor of Part D plans in the market, covering more then 4 million beneficiaries while Member Health has 1.1 million Part D members. Prime Therapeutics administers Part D Blues plans in 12 states, covering 800,000 beneficiaries. DSI also has contracts with other top 10 Part D sponsors that have not yet been announced.

Dispensing Solutions aims to contract with plans covering up to 80 percent of Part D enrollees by the first quarter of 2008. So far, physicians have also accepted the system very well, the firm said.

How The System Works
Vaccine Manager is designed to be used in the physician's office during the patient visit. When physicians see a patient who is a candidate for a Part D vaccine, their office contacts the patient's plan, which then returns verification of coverage. Participating plans also send= information on the member's financial responsibility.

If the patient agrees to the vaccination, the physician collects the co-pay from the patient and submits the claim to the plan via the system for the remainder of the contracted cost.

Use of the system is expected to lead to increased access for Zostavax, which has presented a unique set of reimbursement challenges under Medicare ("The Pink Sheet" Sept. 4, 2006)

Because it is dispensed in a physician's office, patients have been faced with the prospect of paying the physician's office up front for the vaccine and then submitting a paper claim to their plan for reimbursement.

The system is designed to fill the gap in physician office capabilities in processing pharmacy claims and also address the fact that health plans do not usually communicate directly with physicians on prescriptions. eDispense Vaccine Manager was launched in August.

CMS issued guidance in December 2006 supporting use of a Web portal for such vaccine claims. In a memo to Part D sponsors, the agency pointed out that “utilization of this Web-assisted concept has several benefits,” including increasing access to physician-administered vaccines.

Zostavax is indicated for patients age 60 and older. However, uptake since its 2006 introduction has been somewhat slower than expected, with sales totaling $61 million in the third quarter.

Further complicating the reimbursement environment for Zostavax has been coverage of physician administration fees. When the vaccine launched there was confusion in the market on how to bill for such fees.

Administration is being covered in 2007 under Medicare Part B, which covers most physician services, but will be covered under the Part D in 2008. The Vaccine Manager contracts will include administration fees for 2008, DSI said.
There are approximately 40 vaccines covered by Part D, including hepatitis A and B, and tetanus, when administered for prevention. These other vaccines are included in most of the eDispense contracts, according to DSI.

Applications Outside Part D
Although the system is initially being promoted for Part D vaccines, the technology involved could work with any type of pharmacy benefit involving drugs dispensed or administered in the office or practice setting, DSI said. The firm is working to adapt the Vaccine Manager technology to offer retail claims adjudication capabilities to commercial plans in 2008.
- Cathy Kelly c.kelly@elsevier.com)

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