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| Medical Policy: | I-8-069 |
| Topic: | Immunizations |
| Section: | Injections |
| Effective Date: | July 1, 2018 |
| Issue Date: | July 2, 2018 |
| Last Reviewed: | May 2017 |
Patient Protection and Affordable Care Act, as amended (PPACA) (Enacted 3/23/2010) Refer to the current year’s Preventive Schedule for guidelines on the Provider Resource Center for when and how often the following immunizations are recommended. This schedule is a reference tool for planning preventive care, and lists items/services required under the Patient Protection and Affordable Care Act of 2010 (PPACA), as amended. It is reviewed and updated periodically based on the advice of the U.S. Preventive Services Task Force, laws and regulations and updates to clinical guidelines established by national medical organizations. Accordingly, the content of this schedule is subject to change. Specific needs for preventive immunizations may vary according to member’s personal risk factors. |
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
| Policy Position Coverage is subject to the specific terms of the member’s benefit plan. |
The following mandated immunizations are covered for the insured or the insured spouse who are greater than or equal to 21 years of age, or a dependent child in accordance with the age limits of the individual contracts:
- Diphtheria
- Hemophilus B (HIB)
- Hepatitis A
- Hepatitis B
- Influenza (vaccine recommended annually)
- H1N1, influenza A [H1N1] vaccine
- Fluarix Quadrivalent, influenza subtype A and type B vaccine
- Flucelvax Quadrivalent® MDV
- FluLaval
- Fluzone® intramuscular, quadrivalent
- Fluzone® intradermal, quadrivalent
- RIV4, intramuscular, quadrivalent
- Trivalent influenza virus vaccine
- Flumist (LAIV4), intranasal, quadrivalent – for ages 2-49 years
- Human Papillomavirus
- Gardasil®, Quadrivalent (Types 6, 11, 16, 18) Recombinant Vaccine
- Gardasil 9®, Human Papillomavirus 9-valent (Types 6, 11,16, 18, 31, 33, 45, 52, 58) Recombinant Vaccine, 3 dose schedule.
- Meningococcal
- Meningococcal conjugate vaccine, serogroups A, C, Y, and W-135
- Menactra® meningococcal tetravalent
- Meningococcal conjugate vaccine, serogroups C, Y and Hemophilus influenza B vaccine (Hib-MenCY)
- Meningococcal recombinant protein and outer membrane vesicle vaccine, Serogroup B, 2 dose schedule
- Meningococcal recombinant lipoprotein vaccine, Serogroup B, 3 dose schedule
- Mumps
- Pertussis (whooping cough)
- Pneumonia
- Prevnar pneumococcal conjugate, 13-valent
- Pneumococcal polysaccharide, 23-valent
- Polio
- Rabies
- Rotavirus
- Rubella
- Rubeola (measles)
- Tetanus
- Varicella (chicken pox vaccine)
Other Non-Mandated Immunizations
Other than those specific childhood immunizations listed above, coverage for immunizations is determined according to individual or group customer benefits. Immunizations should be reported under the appropriate procedure code. Immunization is acceptable for the following diseases:
- Cholera
- Diphtheria
- Hemophilus B (HIB)
- Hepatitis A (Based on individual risk or physician recommendation: One two-dose series)
- Hepatitis B (Based on individual risk or physician recommendation: One three-dose series)
- Human Papillomavirus (HPV)(For individual’s age 9 to 26 years old, one three-dose series. Dose 2 at 2 months from Dose 1. Dose 3 at 6 months from Dose 1)
- Influenza (annually)
- Trivalent influenza virus vaccine
- Fluzone intramuscular, quadrivalent
- Fluzone intradermal, quadrivalent
- Japanese encephalitis
- Meningococcal (based on individual risk or physician recommendation: one or two doses per lifetime)
- Mumps
- Pertussis (whooping cough)
- Pneumonia
- (pneumococcal) (high-risk or at age 65: one to two doses as recommended by physician)
- Plague
- Polio
- Rabies
- Rubella
- Rubeola (measles)
- Tetanus
- Tuberculosis (BCG)
- Typhoid fever
- Varicella (chicken pox vaccine ) (one series of two doses at least one month apart for adults with no history of chicken pox)
- Varicella-Zoster
- Yellow fever
- Zoster (shingles vaccine live) (ZOSTAVAX®) (One dose age 60 years of age and older)
- Zoster (shingles vaccine recombinant, adjuvanted) - Shingrix - (Two doses age 50 years of age and older).
Immunizations or injections for diseases other than those listed above are not eligible for payment. Immunizations must be FDA approved to be eligible for payment.
The cholera vaccine (procedure code 90625) is not FDA approved and, therefore, is non-covered.
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| The policy position applies to all commercial lines of business |
| Denial Statements |
A network provider can bill the member for the non-covered service.
| Links |
- Link to Provider Resource Center for the Medical Policy Update
06/2017, Coverage for the Quadrivalent (RIV) Influenza Virus Vaccine
03/2018, Coverage for the Shingles Vaccine Shingrix
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Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
- Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
- Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
