• HMO and POS members are eligible to visit any participating MinuteClinic or Take Care Health Clinic for the novel H1N1 flu vaccine until the end of March 2010, without a copay or referral requirement.
• PPO members are eligible to visit any participating MinuteClinic or Take Care Health Clinic in accordance with their standard benefit plan.

http://www.amerihealth.com/find_a_provider/retail_health_clinics.html

In addition, the Company will continue its coverage of the administration of novel H1N1 flu vaccine for all members. Copayments should not be collected for vaccine administration, and an office visit evaluation and management (E&M) code should not be billed, unless the individual is being treated for a separately identifiable medical problem or service. In these instances, applicable copayment requirements may apply.

Administration of the novel H1N1 flu vaccine is not subject to cost sharing.


Referral/Precertification Requirements:

Referral requirements for HMO members who receive the administration of novel H1N1 flu vaccine will be waived. Administration of the novel H1N1 flu vaccine is not subject to precertification/pre-approval requirements.

Reimbursement:

Provider

• Providers will receive separate reimbursement for the administration of the vaccine.

• Commercial and Medicare Advantage HMO/POS/PPO members who receive either an injectable novel H1N1 flu vaccine or the intranasal novel H1N1 flu vaccine in a setting other than a physician’s office, hospital, or participating MinuteClinic or Take Care Health Clinic (eg, supermarket, pharmacy, workplace) are eligible for reimbursement for the out-of-pocket expense, up to a maximum of $25.00. Member reimbursement requires the submission of a paid receipt or invoice, along with the specific novel H1N1 flu vaccine claim form used to process this service. This claim form can be obtained by contacting Member Services or through ibx.com. Coverage of the administration of the novel H1N1 vaccine will be processed through the member’s medical benefit, not their pharmacy benefit.

• 90663: Influenza virus vaccine, pandemic formulation, H1N1

• G9142: Influenza A (H1N1) vaccine, any route of administration

• 90470: H1N1 immunization administration (intramuscular, intranasal), including counseling when performed

• G9141: Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family)

• V04.81: Need for prophylactic vaccination and inoculation, influenza

Novel H1N1 is a flu virus of swine origin that first caused illness in Mexico and the United States in March 2009. According to the CDC, the novel H1N1 flu spreads in the same way that standard seasonal influenza viruses spread, mainly through the coughs and sneezes of individuals who are sick with the virus, but it also may be spread by touching infected objects and then touching the nose or mouth. The novel H1N1 flu virus has been reported to cause a wide range of typical flu-like symptoms, including fever, cough, sore throat, body aches, headache, chills, and fatigue. In addition, many people also have reported nausea, vomiting, and diarrhea.

Influenza vaccination is the most effective method for preventing influenza and influenza-related complications. However, current seasonal flu vaccines are not likely to provide protection against the novel H1N1 flu virus. According to the CDC, the novel H1N1 vaccine will be procured and purchased by the federal government and made available to vaccinators at no cost. Private providers who wish to administer the novel H1N1 flu vaccine will need to enter into relationships with their public health department so that the vaccine can be directed to them.

The novel H1N1 flu vaccine is being developed as both an injectable and intranasal spray and is expected to be available in a combination of settings such as vaccination clinics organized by local health departments, healthcare provider offices, schools, and other private settings (eg, pharmacies, workplaces).

Several novel H1N1 vaccines have received US Food and Drug Administration (FDA) approval. The manufactures include: CSL Limited, MedImmune LLC, Novartis Vaccines and Diagnostics Limited, and Sanofi Pastuer Inc. Although the novel H1N1 flu vaccines are being manufactured using the same process, the FDA-approved labeling may vary.

Recommendations of the CDC’s Advisory Committee on Immunization Practices (ACIP):

While the signs and symptoms of the novel H1N1 flu virus are similar to those of seasonal influenza, a comparison of the age distribution of hospitalized individuals with laboratory-confirmed novel H1N1 flu virus infection demonstrates a striking difference. The ACIP recommends that certain groups of the population receive the novel H1N1 flu vaccine when it first becomes available. These key populations include:

• Pregnant women
• Individuals who live with or care for children younger than 6 months of age
• Health care and emergency services personnel
• Children and young adults from 6 months to 24 years old Individuals 25 though 64 years old who have chronic medical conditions that increase their risk of complications from influenza infection

Per the FDA recommendations, children 6 months to 9 years of age should be administered two doses of the novel H1N1 monovalent flu vaccine, with 21-28 days between the first and second vaccination. Adults and children 10 years of age and older should be administered one dose of the novel H1N1 monovalent flu vaccine.

Please note: This article addresses the novel H1N1 (swine) flu vaccine administration only. This is not relevant to immunization for seasonal flu. Please refer to our article: Coverage of Standard Seasonal Influenza Vaccine for 2009-2010, for coverage information.

Additionally, the information contained in this article is subject to change based on updated recommendations from the CDC, the CDC's Advisory Committee on Immunization Practices (ACIP), and other local, state, and federal health organizations. When new recommendations are published, the Company will provide updated information as needed.

If you have any questions, contact your Network Coordinator.

Related Policy:

07.00.15f, Reimbursement for the Administration of Immunizations

00.10.01m, Services Paid Above Capitation for Pennsylvania Health Maintenance Organization (HMO) Primary Care Physicians

Please note: This article supersedes the previous articles on Coverage for the Administration of Novel H1N1 (Swine) Flu Vaccine for 2009-2010, published 09/03/09 and 09/11/09.