 | The Company will continue its coverage of either an injectable influenza vaccine or the intranasal influenza vaccine for managed care members during the 2009-2010 seasonal influenza season, when a benefit for immunizations exits. However, the Company has updated its coverage to allow Commercial and Medicare Advantage HMO/POS/PPO members to visit any participating MinuteClinic or Take Care Health Clinic for administration of either the injectable or intranasal seasonal influenza vaccine without out-of-pocket expense.
Eligibility:
When a benefit for immunizations exists, either an injectable influenza vaccine (Afluria®, Fluarix®, Flulaval®, Fluvirin®, or Fluzone®) or the intranasal influenza vaccine (FluMist®) will be covered for managed care members during the 2009-2010 seasonal influenza season. Coverage may be subject to applicable deductible and coinsurance requirements. Copayments should not be collected for the vaccine or 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.
Commercial and Medicare Advantage HMO/POS/PPO members will be able to visit any participating MinuteClinic or Take Care Health Clinic for administration of either an injectable influenza vaccine (Afluria®, Fluarix®, FluLaval®, Fluvirin®, or Fluzone®) or the intranasal influenza vaccine (FluMist®) without out-of-pocket expense, subject to the following:
- HMO and POS members are eligible to visit any participating MinuteClinic or Take Care Health Clinic for the standard seasonal 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.
For a list of participating retail clinics, refer to the following link:
http://www.amerihealth.com/find_a_provider/retail_health_clinics.html
For Commercial and Medicare Advantage members, standard injectable and intranasal seasonal influenza vaccines are solely available under the medical benefit. These vaccines are not covered under the pharmacy benefit.
Reimbursement:
Provider
- Eligible providers will receive separate reimbursement for both the seasonal influenza vaccine and the professional component of administering the vaccine.
Member
- Commercial and Medicare Advantage HMO/POS/PPO members who receive either an injectable influenza vaccine (Afluria®, Fluarix®, FluLaval®, Fluvirin®, or Fluzone®) or the intranasal influenza vaccine (FluMist®) 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 $25.00. Coverage may be subject to applicable deductible and coinsurance requirements. Member reimbursement requires the submission of a paid receipt or invoice, along with the specific claim form used to process this type of service. This claim form can be obtained by contacting Member Services or through ibx.com. Coverage of the vaccine will be processed through the member’s medical benefit, not their pharmacy benefit.
Referral Requirements:
Referral requirements for HMO members who receive the influenza vaccine from a participating provider will be waived during the 2009-2010 seasonal influenza season. Providers are required to use the following Current Procedural Terminology (CPT®) codes to report standard injectable vaccines (Afluria®, Fluarix®, FluLaval®, Fluvirin®, or Fluzone®):
90655: Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use
90656: Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use
90657: Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use
90658: Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use
Providers are required to use the following CPT code to report the intranasal influenza vaccine (FluMist®):
90660: Influenza virus vaccine, live, for intranasal use
About the Seasonal Flu:
In the United States, annual epidemics of influenza occur seasonally during the late fall through early spring. The influenza viruses can cause disease among individuals in any age group. However, the rates of infection and serious illness are highest in individuals 65 years of age and older, children younger than 2 years of age, and individuals of any age who have medical conditions that place them at increased risk for complications from the virus. Standard seasonal flu vaccination began in September when the vaccine became available and will continue throughout the influenza season, into December, January, and beyond. This is because the timing and duration of influenza seasons vary.
Recommendations of the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (ACIP):
The 2009 recommendations include new and updated information. Principal updates and changes include:
- A new recommendation that annual vaccination be administered to all children age 6 months through 18 years, beginning in the 2009-2010 seasonal influenza season
- A new recommendation that annual seasonal influenza vaccination of all children age 6 months through 4 years, and older children with conditions that place them at increased risk for complications from influenza, should continue to be a primary focus of vaccination efforts as providers and programs transition to routinely vaccinating all children
- A new recommendation that vaccines containing the 2009-2010 trivalent vaccine virus strains A/Brisbane/59/2007 (H1N1)-like, A/Brisbane/10/2007 (H3N2)-like, and B/Brisbane 60/2008-like antigens be used
- New information on antiviral resistance among seasonal influenza viruses in the United States
For a complete listing of the 2009 ACIP recommendations, visit:
http://www.cdc.gov/mmwr/pdf/rr/rr5808.pdf.
Please Note: The seasonal influenza vaccine is not expected to protect against the novel H1N1 (swine) flu. This communication addresses the standard seasonal influenza vaccine only. This is not relevant to immunization for novel H1N1 (swine) flu. Please refer to our article: Coverage for the Administration of Novel H1N1 (Swine) Flu Vaccine, for coverage information.
If you have any questions, contact your Network Coordinator.
Related Policies:
00.10.01m, Services Paid Above Capitation for Pennsylvania Health Maintenance Organization (HMO) Primary Care Physicians
07.00.15f, Reimbursement for the Administration of Immunizations
Please note: This article supersedes the previous articles on Coverage of Standard Seasonal Influenza Vaccine for 2009-2010, published 09/03/09 and 09/11/09.
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