New process for submitting Part D immunizations for PriorityMedicare members

What’s happening?

Effective January 1, 2026, we’re introducing a new process for handling Part D vaccine claims for PriorityMedicare members when administered in a physician’s office. Part D vaccines given in a doctor’s office are not covered under the medical benefit for Medicare members. For PriorityMedicare Dual Premier (HIDE-SNP) members, these claims will automatically be denied as provider liability. Providers may not bill Dual Premier members for any balance.

What’s changing?
The process for submitting Part D vaccine claims for all PriorityMedicare members is changing. Members should be directed to obtain their Part D-covered vaccines at a vaccine network pharmacy, but for members who insist on receiving Part D vaccines in a provider’s office or outpatient clinic, providers should submit these claims for Part D immunizations through www.transactrx.com.

PriorityMedicare / D-SNP processPriorityMedicare Dual Premier (HIDE-SNP) process

Member should get Part D vaccines at a Vaccine Network pharmacy.

If administered at a physician’s office or outpatient clinic, the provider can either:

  • Bill TransactRx to avoid the member payment/reimbursement process, or
  • Collect payment from the member, and the member submits for reimbursement from PH (current process).

If billed directly to us, the claim will deny as member liability.

Member should get Part D vaccines at a Vaccine Network pharmacy.

If administered at a physician’s office or outpatient clinic, the provider must bill TransactRx for payment.

If billed directly to us, the claim will deny as provider liability. Providers must then rebill to TransactRx.

Providers may not bill the member for the vaccine or its administration.

 

For more details, refer to the Provider Manual.