Childhood Immunization Insurance Act (Act 35 of 1992)
CHILDHOOD IMMUNIZATIONS (Effective 11/21/1992)

The following mandated immunizations are covered for individuals who are up to and including 20 years of age:

  Diphtheria
  Hemophilus B (HIB)
  Hepatitus A
  Hepatitis B
*Influenza
*Meningococcal
  Mumps
  Pertussis (whooping cough)
*Pneumonia
    Pneumoccal conjugate, 7-valent (e.g., Prevnar)(90669)
    Pneumoccal polysaccharide, 23-valent (90732)
  Polio
  Respiratory Syncytial Virus (RSV)
  Rubella
  Rubeola (measles)
  Tetanus
  Varicella (chicken pox vaccine-90716)

NOTE:

These three immunizations are eligible under the mandate for individuals up to and including 20 years of age who are medically high-risk as defined in the Advisory Committee on Immunization Practices (ACIP) recommendations. These recommendations can be referenced at www.cdc.gov/mmwr

Highmark/Pennsylvania Blue Shield does not recognize pre-college admission, or ongoing college attendance as high risk per the ACIP recommendations. Therefore, meningococcal vaccination would not be covered in those circumstances. A participating, preferred, or network provider may bill the member for the vaccine.

Also, gamma globulin (codes 90281, J1460-J1560) and immune globulin (codes 90283, 90379, 90389, 90396, J1561, J1563, J1565, J1670) are covered as immunizations.

COMVAX (90748), a combination of the hemophilus influenza B (HIB) and hepatitis B vaccines, is a covered immunization procedure.

Twinrix® (90636), a combination of the hepatitis A virus (HAV; HAVRIX®) and hepatitis B virus (HBV; Energix-B®) vaccines, is a covered immunization procedure for individuals 18 years of age or older.

Furthermore, reported combinations of the above vaccines are also eligible for payment, e.g., DPT (diphtheria and tetanus toxoids plus pertussis vaccine) is a commonly used combined immunization procedure.

NOTE:

The following codes are applicable to the childhood immunizations listed above: (90281, 90283, 90371, 90375-90376, 90378, 90379, 90389, 90396, 90632, 90633, 90634, 90636, 90645-90648, 90657-90659, 90669, 90675-90676, 90700-90709, 90712, 90713, 90716, 90718-90721, 90732-90733, 90740-90748, J1460-J1560, J1561, J1563, J1565, and J1670.)

NOTE:

Effective October 15, 1999, the FDA has withdrawn the rotavirus vaccine from the market because of incidents of intussusception after vaccination. Therefore, the rotavirus vaccine (90680) is no longer considered medically appropriate treatment and will be denied as not covered. A participating, preferred, or network provider cannot bill the member for the denied service.

Other than those specific childhood immunizations listed above, immunizations are covered only under specific Highmark/Pennsylvania Blue Shield contracts. When a claim is received for an immunization, it should be processed for payment under the appropriate procedure code. Immunization is acceptable for the following diseases:

Cholera
Diphtheria
Hepatitis A
Influenza
Meningococcal
Mumps
Pertussis (whooping cough)
Pneumonia
Plague
Polio
Rubella
Rubeola (measles)
Tetanus
Tuberculosis (BCG)
Typhoid fever
Varicella (chicken pox vaccine-90716)
Varicella-Zoster (immunoglobulin-90396)
Yellow Fever

Twinrix® (90636), a combination of the hepatitis A virus (HAV; HAVRIX®) and hepatitis B virus (HBV; Energix-B®) vaccines, is a covered immunization procedure for individuals 18 years of age or older.

Rh Immune Globulin is an accepted immunization procedure for mothers who have Rh negative blood type.

NOTE:

In addition to the procedure codes listed under the childhood immunizations, the following codes are applicable to the other immunizations: (90585, 90632-90634, 90636, 90690-90692, 90717, 90725, 90727, 90735, 90740, 90746, 90747, and 90749).

NOTE:

A separate administration fee can be reported with each separately administered immunization. Codes G0008-G0010, G0190-G0191, and 90471-90472 should be reported as appropriate in addition to immunization procedures 90281, 90283, 90371-90379, 90389, 90396, 90585, 90632-90634, 90645-90648, 90657-90659, 90669, 90675-90676, 90691-90692, 90700-90709, 90713-90721, 90725-90744, 90746-90749, J1460-J1563, J1565, and J1670. (This applies to all patients, regardless of age, who have coverage for immunizations.) If codes G0008-G0010, G0190-G0191, 90471-90472 are reported with codes other than those specified or, if they are reported as the sole service they will be denied as not covered. A participating, preferred, or network provider cannot bill the member for the denied service.

NOTE:

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.

The information outlined above on childhood immunizations does not apply to the Federal Employee Program.

Meningococcal vaccine (90733) is eligible under other medical benefits for members who have been exposed to the disease, or are considered high risk for contracting the disease.

Managed Care

Immunizations administered for foreign travel are not covered.

PRN References

06/1993, Immunizations, local code
10/1993, Immunizations pricing
10/1994, Administration of therapeutic injectables and immunizations
03/1995, Immunization administration
08/1995, Chicken pox vaccine
08/1995, Hepatitis A vaccine
12/1996, Immunization administration fees
02/1997, Immunization procedure code 90721
06/1997, FDA approves new immunization procedure
12/1997, Use appropriate codes when reporting immunizations
04/1999, Rotavirus
08/1999, Use specific codes to report respiratory syncytial virus immune globulin
02/2000, FDA orders withdrawal or rotavirus vaccine
02/2000, Eligibility guidelines for influenza, meningococcal, and pneumococcal vaccines
04/2000, Blue Cross Blue Shield may pay for FDA-approved pneumococcal vaccines
10/2000, Blue Cross Blue Shield issues new coverage guidelines for Prevnar™
04/2001, Blue Cross Blue Shield to follow ACIP guidelines for Prevnar™
08/2001, New combination vaccine for hepatitis

Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP), Morbidity/Mortality Weekly Report, 49 (RR-03); 1-38, 4/2000

Control and Prevention of Meningococcal Disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP), Morbidity/Mortality Weekly Report, 46 (RR-5); 1-51, 2/1997

Prevention of Pneumococcal Disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP), Morbidity/Mortality Report, 46 (RR-08); 1-24, 4/1997

Immunizations of Adolescents: Recommendations of the Advisory Committee on Immunization Practices, The American Academy of Pediatrics, The American Academy of Family Physicians, and the American Medical Association, American Academy of Pediatrics, Vol. 99, No. 3, 3/1997

Recommendations for the Prevention of Pneumococcal Infections, Including the Use of Pneumococcal Conjugate Vaccine (Prevnar), Pneumococcal Polysaccharide Vaccine, and Antibiotic Prophylaxis (RE9960), American Academy of Pediatrics, Policy Statement, Vol. 106, No. 02, August, 2000