The administration of covered immunizations and vaccines also is covered.
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1 Covered Benefit: Immunization & Vaccines Definitions: CMP Published: Yes No CMP Link: CPG Link: Pediatric, Adolescent and Adult Routine Preventative Services Immunizations and vaccinations for treatment of disease or prevention of infectious disease are covered. Neighborhood covers a set of immunizations and vaccines inclusive of the RI Department of Health s State Supplied Vaccine Schedule for children and adults. In addition to the State s Schedule, Neighborhood s Clinical Management Committee approves coverage of additional immunizations and vaccines that align with the benefit coverage dictated by its contract with the Department of Human Services. The administration of covered immunizations and vaccines also is covered. State supplied vaccines are provided by the DOH at no cost to providers and practitioners; therefore there is no reimbursement for the actual state supplied vaccines; although administration is covered. Benefit Packages: RIte Care, Substitute Care, Children with Special Health Care Needs, Rhody Health Partners and Rhody Health Options Phase One. Coverage Limitations: Immunizations and vaccines that are typically part of the routine well-child care are covered when administered by the member s PCP or a covering practitioner for the member s PCP, see Table 2. These immunizations and vaccines are also covered when administered at a School Based Health Center. Other immunizations and vaccines are covered with no restrictions, see Table 3. Exclusions: The vaccines and immunizations listed on Table 1. Noncovered Immunizations and Vaccines are not covered. Table 1 includes vaccines and immunizations for travel which are not covered. Extended Family Planning (EFP) members are excluded; EFP members do not have a comprehensive benefit package. Immunization and Vaccines Page 1
2 Table 1. NON-COVERED Immunizations and Vaccines as of 07/15/13: Only immunizations and vaccines that are not covered for ANY age member are listed in Table 1. PROCEDURE CODE DESCRIPTION H1N1 IMMUNIZATION ADMINISTRATION (INTRAMUSCULAR, INTRANASAL), INCLUDING COUNSELING WHEN PERFORMED ADENOVIRUS VACCINE, TYPE ADENOVIRUS VACCINE, TYPE ANTHRAX VACCINE, SC BCG VACCINE, PERCUTANEOUS BCG VACCINE, INTRAVESICAL HEP A VACCINE, PED/ADOL 3 DO HIB VACCINE, HBOC, IM MENINGOCOCCAL (Hib-Men CY-TT) 4 DOSE, 2-15 MO, HIB VACCINE, PRP-D, IM Effective 7/15/13 HIB VACCINE, PRP-T, ActHIB HPV TYP BIVAL 3 DOSE IM INFLUENZA VACCINE PRSV FREE ID USE FLU VACCINE, 6-35 MO, IM Effective 7/15/13 FLU VACCINE, QUADRIVALENT, FLULAVAL, IM Effective 7/15/13 FLU VACCINE, TRIVALENT, FLUMIST, IN FLU VACC CELL CULT PRSV FREE FLU VACC PRSV FREE INC ANTIG FLU VACC PANDEMIC H1N1 INFLUENZA VIRUS VACCINE, PANDEMIC FORMULATION, LIVE FOR INTRANASAL USE LYME DISEASE VACCINE, IM INFLUENZA VIRUS VACCINE, PANDEMIC FORMULATION, SPLIT VIRUS, PRESERVATIVE FREE, FOR INTRAMUSCULAR USE INFLUENZA VIRUS VACCINE, PANDEMIC FORMULATION, SPLIT VIRUS, ADJUVANTED, FOR INTRAMUSCULAR USE PNEUMOCOCCAL VACCINE, PED ROTAVIRUS VAC, TETRAVALENT L Immunization and Vaccines Page 2
3 90690 TYPHOID VACCINE, ORAL TYPHOID VACCINE, IM TYPHOID VACCINE, H-P, SC/ID TYPHOID VACCINE, AKD, SC DTAP-HIB-IP VACCINE, IM MUMPS IMMUNIZATION MEASLES IMMUNIZATION RUBELLA IMMUNIZATION MEASLES-RUBELLA IMMUNIZATION ORAL POLIOVIRUS IMMUNIZATION YELLOW FEVER IMMUNIZATION DIPHTHERIA IMMUNIZATION DTP/HIB IMMUNIZATION DIPTHERIA, TETANUS, TEXOIDS, CHOLERA IMMUNIZATION PLAGUE IMMUNIZATION ENCEPHALITIS VIRUS IMMUNIZAT JAPENESE ENCEPHALITIS HEP B VACC, ADOL, 2 DOSE, IM IMMUN HEPAT B DIALYSIS ANY A IMMUN HEPAT B AND HIB VACCIN IMMUNIZATION PROCEDURE NEC G0008 ADMIN OF INFLUENZA G0009 ADMIN OF PNEUMOCOCCAL VACCIN G0010 ADMIN OF HEPATITIS B VACCINE T1502 ADMINISTRATION OF ORAL, INTR Coverage Includes: Immunizations and vaccines are covered when administered per Table 2 - Member s PCP or Covering Practitioner, or Table 3 - Any Provider, at the places of service listed below. Please note, a PCP may be located at a physician s office, a hospital outpatient department, or a community health center. School based health centers are treated as PCP sites for the purposes of immunization and vaccine administration. Note: bands within Tables 2 and 3 below are for general understanding only, code specific CPT age bands will be applied at the time of claims adjudication. SSV=State Supplied Vaccine Pay=Covered by Neighborhood NC=Not Covered for indicated age band Immunization and Vaccines Page 3
4 Table 2. Covered Immunization and Vaccination when administered by member s PCP or Covering Practitioner PROCEDURE /01/11 thru 7/14/13 Description HEP A VACCINE, ADULT, IM NC Pay NC SSV 07/15/13 thru present HEP A VACCINE, PED/ADOL 2 DO SSV NC SSV NC HEP A/HEP B VACCINE ADULT IM NC Pay NC Pay HIB VACCINE, PRP-OMP, IM SSV NC SSV SSV HIB VACCINE, PRP-T, IM SSV SSV NC NC PNEUMOCOCC AL VACC; 13 VAL IM SSV NC SSV SSV ROTAVIRUS VACC 2 DOSE ORAL SSV NC SSV NC MMR VIRUS IMMUNIZATIO N SSV Pay SSV SSV Immunization and Vaccines Page 4
5 Table 2. Continued /01/11 thru 7/14/13 8/01/11 thru 7/14/ H PAPILLOMA VACC 3 DOSE IM SSV For females and males, HPV vaccine is covered from the age of 11 to If a member has begun the series by age 28.99, the Plan will cover the completion of the series by age with prior authorization. HPV vaccine, CPT code 90649, is covered as a state supplied vaccine from age ; by the Plan from age ; and for members who begin the 3- shot series by age 28.99, the 2nd and 3rd shot of the series will be covered up to age with authorization. HPV vaccine is covered when administered by members PCP or covering practitioner or when administered by a provider with specialty of OB/GYN. Immunization and Vaccines Page 5
6 Table 2. Continued MEASLES- MUMPS- RUBELLA IMMUNI Pay Pay POLIOMYELITIS Payable by Neighborhood age 0 to 3.99 and age 7 to PCP SSV age 4 to 6.99 Pay IMMUNIZATION SSV Pay SSV Pay CHICKEN POX IMMUNIZATION SSV Pay SSV SSV TD Deleted Code IMMUNIZATION NC Pay 1/1/13 PNEUMOCOCCAL IMMUNIZATION SSV SSV SSV SSV MENINGOCOCCA L IMMUNIZATION NC Pay NC Pay MENINGOCOCCA L VACCINE, IM SSV Pay SSV SSV ZOSTER VACC; SC NC Pay NC Pay HEPB VACC, ILL PAT 3 DOSE IM NC Pay NC Pay HEPAT B SSV up to age VACCINE, PEDI SSV NC 19 HEPAT B VACCINE, ADULT NC Pay NC SSV Table 3: Covered Immunizations and Vaccines ANY PROVIDER PRO C /01/11 thru 7/14/13 Description FLU VACCINE, 6-35 MO, IM SSV NC SSV NC FLU VACCINE, QUAD, 3 & >, IM NC NC SSV SSV Deleted Code 1/1/13 NC age 20 and up 07/15/13 thru present FLU VACCINE, QUAD, 2 18YRS, NASAL NC NC SSV NC FLU VACCINE NO SSV SSV NC SSV Immunization and Vaccines Page 6
7 PRO C 08/01/11 thru 7/14/ /15/13 thru present Description PRESERV 19 & > FLU VACCINE, YRS, IM NC SSV NC NC FLU VACCINE, IN SSV NC NC NC RABIES VACCINE, IM Pay Pay Pay Pay RABIES VACCINE, ID Pay Pay Pay Pay DTAP-IPV VACC YR IM SSV NC SSV NC DTAP IMMUNIZATION SSV NC SSV NC DTP IMMUNIZATION NC Pay NC Pay DT IMMUNIZATION SSV NC SSV NC TETANUS IMMUNIZATION Pay Pay Pay Pay TETANUS AND DIPTHERIA SSV Pay SSV SSV TDAP VACCINE >7 IM SSV SSV SSV SSV DTAP-HEP B-IPV VACCINE, IM SSV NC SSV NC Table 4: Administration Codes PROC Description Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure) Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) Immunization and Vaccines Page 7
8 90473 Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid) Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) For information regarding immunoglobulin coverage, including tetanus, rabies, and Rhogam, please refer to the Pharmaceutical Benefit Coverage Summary. VERSION HISTORY: Create Date: 03/05/10; Revision Date: 05/17/10; 09/09/10; 10/22/10, 12/22/10, 7/23/12, 5/6/13, 09/01/013, 09/25/13 PEC: 10/24/13 Immunization and Vaccines Page 8
The administration of covered immunizations and vaccines also is covered.
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