Clinical Update for Medicare Part D

eDispense Vaccine Manager Operational for ZOSTAVAX

Physicians now have an option for easy on-line access to submit claims for ZOSTAVAX (when administered from their office supply) to Prime Therapeutics (Prime) for Medicare Part D coverage. This new service, called eDispense Medicare Part D Vaccine Manager, allows physicians to submit a real-time claim from their office system to verify the member’s coverage and coverage level prior to administering the vaccine. This service, which is administered by Dispensing Solutions, Inc. (DSI) is currently only available for ZOSTAVAX (due to the unique storage requirements).

When a physician is seeing a patient who is a candidate for ZOSTAVAX, he or his office staff, submits a claim for ZOSTAVAX which is converted to a pharmacy NCPDP 5.1 claim and forwarded on to Prime. Prime then processes it as a network pharmacy claim, and returns verification of coverage and the member’s financial responsibility (co-payment or coinsurance) to the physician’s office. With this information, the physician can discuss the vaccination and coverage level with the patient prior to administration and the patient can decide whether to receive the vaccine. If the patient agrees to the vaccination, the ZOSTAVAX is administered, and the physician collects the co-payment, as transmitted with the processed claim, from the member. The physician will receive the remainder of the (contracted) cost of ZOSTAVAX via payment from DSI.

Physicians can participate by enrolling in the eDispense network at http://enroll.edispense.com, and completing the brief enrollment process. Physicians can contact DSI with any questions at 866-522-EDVM (866-522-3386). Please refer to the attached EDVM brochure for additional information.

DSI is working with the individual plans’ Provider Relations departments on the physician enrollment process, which is already underway.

In addition to this new on-line service, ZOSTAVAX remains on our Medicare formularies, and can also be obtained through any of the following methods:

• By prescription at any pharmacy provider willing and able to handle the product. The vaccine should then be delivered to the physician’s office immediately for administration to maintain product integrity and efficacy. After removal from the freezer, reconstitution and drug administration should occur within a 30-minute time frame.
• Administered from physician supply, with reimbursement requested through the standard paper claims process by either the physician or member

Through eDispense Medicare Part D Vaccine Manager, physician providers have a new online tool to obtain coverage of ZOSTAVAX for their Medicare Part D patients. This means increased access to vaccines (ZOSTAVAX) for your members.

© Prime Therapeutics LLC, 2007

This information is proprietary and confidential to Prime Therapeutics LLC