 | The Company will continue its coverage of either an injectable influenza vaccine or the intranasal influenza vaccine for managed care members during the 2010-2011 seasonal influenza season, when a benefit for immunizations exits.
ELIGIBILITY
When a benefit for immunizations exists, either an injectable influenza vaccine (Afluria®, Agriflu®, Fluarix®, Flulaval®, Fluvirin®, or Fluzone®) or the intranasal influenza vaccine (FluMist®) will be covered for managed care members during the 2010 - 2011 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.
Please Note: For members who have the 100 percent Preventive benefit, there are no cost-sharing requirements (such as a copayment, coinsurance, or deductible) for the vaccine and administration of the vaccine.
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®, Agriflu®, 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 flu vaccine until the end of March 2011, 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.
Members enrolled in a Comprehensive Major Medical (CMM) or Traditional Benefit Plan will be covered in accordance with their current benefit plan for routine immunizations. Covered services may be subject to benefit restrictions as well as applicable deductible and coinsurance requirements.
REFERRAL REQUIREMENTS
Referral requirements for HMO members who receive the influenza vaccine from a participating provider will be waived during the 2010-2011 influenza season.
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®, Agriflu®, 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 for each dose. For individuals who receive two doses based on Advisory Committee on Immunization Practices (ACIP) recommendations, reimbursement may be made for up to $25.00 for each dose. 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 amerihealth.com. Coverage of the vaccine will be processed through the member’s medical benefit, not their pharmacy benefit.
Providers are to use the following Current Procedural Terminology (CPT®) codes to report Influenza Injectable Vaccines (AFLURIA®, AGRIFLU®, 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
90662: Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, 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
The following CPT Category I codes and Healthcare Common Procedure Codes (HCPCS) Level II codes represent the novel H1N1 (Swine) flu vaccine and administration. (Note: These codes are not eligible for separate reimbursement.)
90470: H1N1 immunization administration (intramuscular, intranasal), including counseling when performed
90663: Influenza virus vaccine, pandemic formulation, H1N1
G9141: Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family)
G9142: Influenza A (H1N1) vaccine, any route of administration
RECOMMENDATIONS OF THE CENTERS FOR DISEASE CONTROL AND PREVENTION ADVISORY COMMITTEE ON IMMUNIZATION PRACTICES (ACIP)
The 2010 recommendations include new and updated information. Principal updates and changes include:
- A new recommendation that all persons aged 6 months and older should receive the influenza vaccine annually.
- A new recommendation that all children aged 6 months to 8 years who did not receive at least 1 dose of a novel H1N1 vaccine should receive 2 doses of a 2010-2011 influenza vaccine, regardless of previous influenza vaccination history.
- A new recommendation that vaccines containing the 2010-2011 trivalent vaccine virus strains A/California/7/2009 (H1N1)-like, A/Perth/16/2009 (H3N2)-like, and B/Brisbane/60/2008-like antigens be used.
- A recommendation that protection of persons at higher risk for influenza related complications should continue to be a focus of vaccination efforts as providers and programs transition to routine vaccination of all persons aged 6 months or older.
The ACIP also provides guidance regarding high-risk groups to be targeted in the event of a significant shortage of vaccine.
For a complete listing of the 2010 ACIP recommendations, visit: http://www.cdc.gov/mmwr/PDF/rr/rr5908.pdf.
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.
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 Centers for Disease Control and Prevention, 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. The novel H1N1 influenza virus is expected to continue to occur during the future winter influenza seasons in the Northern and Southern Hemispheres.
The 2010-2011 influenza vaccine is a single vaccine that will protect against both the standard seasonal flu viruses (H3N2 virus & influenza B virus) and the novel H1N1 flu virus.
If you have any questions, please 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
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