Public Statement: Medical Policy. Effective Date: 01/01/2012 Revision Date: 03/24/2014 Code(s): Many. Document: ARB0454:04.

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1 ARBenefits Approval: 01/01/2012 Effective Date: 01/01/2012 Revision Date: 03/24/2014 Code(s): Many Medical Policy Title: Immunization Coverage Document: ARB0454:04 Administered by: Public Statement: 1. Immunizations recommended for routine administration to children and adults by the Center for Disease Control of the US Department of Health, or similarly authoritative body, will be covered under the preventive medicine benefit. Coverage includes payment both for the cost of the immunization materials and for the administration fee. Immunizations not covered as routine and which are intended primarily for travel, or required for work, school or camp, are not covered. 2. Immunizations other than those recommended for routine use may be required for medical indications, such as exposure to a potentially rabid animal. These immunizations will be covered under the if they are determined to be medically necessary. 3. Influenza immunization (flu shots) will be covered at any location provided; no prescription is required. Human Papilloma Virus (Gardisil) and Shingles immunizations are covered through the pharmacy or at a physician s office. (Shingles vaccine requires a prescription from a physician). All other covered immunizations must be provided through a physician s office. Medical Policy Statement: An immunization is a routinely administered medication to prevent a specific disease in someone with a normally functioning immune system. Some immunizations are offered at sites other than a physician s office, such as a retail pharmacy. ARBenefits believes that immunizations should be directed by and coordinated by the patient s physician. Infant Through age 6 Immunizations: The following immunizations for children age birth to 6 years of age are recommended by the Center for Disease Control and the National Immunization Program. (See Attachment A: Recommended Childhood Immunization Schedule and Catch up Schedule for Children and Adolescents.) Page 1 of 10

2 90633, Hepatitis A (age 12 months or older) Hemophilus influenza type B 90655, 90657, 90685, Influenza for children age 6 months to 3 years 90656, 90658, 90686, Influenza 3 years and older 90660, Influenza, live, attenuated (age 2 years or older) Pneumococcal Conjugate Vaccine 7 valent Pneumococcal Conjugate Vaccine 13 valent Rotavirus (RotaTeq) (maximum age for the first dose 14 weeks and 6 days; maximum age for the last dose 32 weeks 0 days) Rotavirus (Rotarix) (first dose at 6 weeks, second dose before 24 weeks) DtaP-IPV (ages 4 through 6) DTaP-Hib-IPV DTaP DPT DT (tetanus/diphtheria, child) Mumps Virus Measles Virus MMR Measles Rubella MMR Varicella Inactivated Polio Varicella (age 12 months or older) Diphtheria DTP-Hib DTaP-Hib DTaP-HepB-IPV Pneumococcal polysaccharide vaccine (age 2 years and older) Hepatitis B, pediatric/adolescent dosage (one series per lifetime) Hepatitis B and Hemophilus influenza b Pneumococcal polysaccharide vaccine (PPSV), 23 valent (age 2 years and older) 90733, Meningococcal vaccine Adolescent (ages 7 through 18 years) Immunizations: 90633, Hepatitis A Human Papilloma virus (HPV) quadrivalent (males or females age 9 or older) Human Papilloma Virus (HPV) bivalent (females age 9 and older) 90656, 90658, Influenza Pneumococcal conjugate vaccine 13-valent Mumps Virus Measles Virus MMR Page 2 of 10

3 Measles Rubella MMR Varicella Inactivated Polio Tdap (tetanus, diphtheria, acellular pertussis, adult) Varicella Diphtheria Pneumococcal polysaccharide vaccine 90733, Meningococcal vaccine 90743, Hepatitis B (one series per lifetime) Adults (age 19 and older): Hepatitis A (through age 24) HPV quadrivalent (males through age 26, females through age 26) 90656, 90658, 90686, Influenza 90660, Influenza, live attenuated (through age 49 years) Influenza, hi dose (age 65 and over) T (tetanus) every ten years Rubella virus Tdap (tetanus, diphtheria, acellular pertussis, adult) once Td (tetanus/diphtheria, adult) every ten years Diphtheria, every ten years Pneumococcal Polysaccharide Vaccine 90733, Meningococcal vaccine Zoster (shingles) (age 50 and older) Hepatitis B (one series per lifetime) Influenza Immunization: ( , 90672, ): The CDC and the American Academy of Pediatrics recommend influenza vaccination for children between 6 months and 23 months of age during flu season. Annual influenza vaccination is recommended for all children ages 6 months and older with high risk conditions. Adults will be covered as recommended by the CDC. Influenza vaccination will be covered at any location without requirement for a physician s prescription. Immunizations Not Routinely Covered: The following sections detail immunizations which are not routinely covered. They may be requested by a member for reasons particular to that member, and be administered by an attending physician who agrees with the need despite the expectation that ARBenefits will not pay for the immunization. In such cases, a specific statement of acknowledgement of financial responsibility (similar to the Medicare ABN) should be signed by the member before the immunization is administered, to advise the member of his/her financial responsibility, and the amount of that responsibility. The member should be advised that the claim may be denied by ARBenefits with no recognition of member liability, but that this does not release the member from financial responsibility to pay for the requested immunization. Page 3 of 10

4 Immunizations Subject to Medical Review: The following immunizations are covered under the when ordered by a physician and will be subject to medical necessity review: Adenovirus ( ) Rabies (90675, 90676) for those with confirmed or presumed rabies exposure. Immunizations required due to outbreak of disease in Arkansas will be covered as medically necessary and reported to the Arkansas Department of Health. These immunizations are subject to medical necessity review: Anthrax Cholera Typhoid Plague vaccine Lyme Disease vaccine Unlisted vaccines Immunizations Not Covered Immunizations not mentioned above as being routinely covered are not a covered benefit even when required for: Travel Employment Camp Attendance at school New vaccines, new combination vaccines, and vaccines given through alternative routes will be reviewed as needed for medical necessity and for appropriateness of coverage according to the member s benefit contract. New vaccines that are duplicates of already available vaccines, or which are different only because of reduced amounts of preservative in them, are not covered unless there is some scientifically demonstrated reason to believe that they are superior. If they are not shown to be superior, they may be covered if the vaccine is available at the same or lower price compared to the standard vaccine. The following immunizations are not covered because they are obsolete, there are better methods to prevent infection than immunization or they are used exclusively for travel: BCG vaccine Japanese encephalitis vaccine (used only for travel) Yellow Fever (used only for travel) Oral Polio (obsolete) Codes Used In This BI: Adenovirus vaccine type 4 Page 4 of 10

5 90477 Adenovirus vaccine type Anthrax vaccine sc or im Bcg vaccine percut Bcg vaccine intravesical Hep a vaccine adult im Hep a vacc ped/adol 2 dose Hep a vacc ped/adol 3 dose Hep a/hep b vacc adult im Meningoccl hib vac 4 dose im Hib vaccine hboc im Hib vaccine prp-d im Hib vaccine prp-omp im Hib vaccine prp-t im Hpv vaccine 4 valent im Hpv vaccine 2 valent im Flu vaccine no preserv id Flu vaccine no preserv 6-35m Flu vaccine no preserv 3 & > Flu vaccine 3 yrs im Flu vaccine 3 yrs & > im Flu vaccine nasal Flu vacc cell cult prsv free Flu vacc prsv free inc antig Flu vacc pandemic intranasal Lyme disease vaccine im Flu vac pandem prsrv free im Flu vac pandemic adjuvant im Flu vac pandemic splt im Pneumococcal vacc 7 val im Pneumococcal vacc 13 val im Influenza, quadrivalent, attenuated Rabies vaccine im Rabies vaccine id Rotavirus vacc 3 dose oral Rotavirus vacc 2 dose oral Influenca,quadrivalent,,6-35 mo Influenza, quadrivalent, >35 mo Influenza, quadrivalent, 6-35 mo Influenza, quadrivalent, >35 mo Typhoid vaccine oral Typhoid vaccine im Typhoid vaccine h-p sc/id Typhoid vaccine akd sc Dtap-ipv vacc 4-6 yr im Page 5 of 10

6 90698 Dtap-hib-ip vaccine im Dtap vaccine < 7 yrs im Dtp vaccine im Dt vaccine < 7 im Tetanus vaccine im Mumps vaccine sc Measles vaccine sc Rubella vaccine sc Mmr vaccine sc Measles-rubella vaccine sc Mmrv vaccine sc Oral poliovirus vaccine Poliovirus ipv sc/im Td vaccine no prsrv >/= 7 im Tdap vaccine >7 im Chicken pox vaccine sc Yellow fever vaccine sc Td vaccine > 7 im Diphtheria vaccine im Dtp/hib vaccine im Dtap/hib vaccine im Dtap-hep b-ipv vaccine im Cholera vaccine injectable Plague vaccine im Pneumococcal vaccine Meningococcal vaccine sc Meningococcal vaccine im Encephalitis vaccine sc Zoster vacc sc Inactivated je vacc im Hepb vacc ill pat 3 dose im Hep b vacc adol 2 dose im Hepb vacc ped/adol 3 dose im Hep b vaccine adult im Hepb vacc ill pat 4 dose im Hep b/hib vaccine im Vaccine toxoid References 1. CDC Recommendations for Lyme disease vaccine American Academy of Pediatrics recommendations, Page 6 of 10

7 3. American Academy of Family Practice Physicians recommendations, 4. National Immunization Information Hotline: ACIP recommendations: CDC website. 6. Prevention and control of meningitis, recommendations of the Advisory Committee on Immunization Practices at: 7. Health and Economic Implications of HPV Vaccination in the United States: NEJM August 2008 at: 8. CDC Immunization schedules at; Immunization Adenovirus CPT code Age (in years, unless otherwise specified) Anthrax BCG (TB vaccine) Not covered Cholera Diphtheria any DT and combinations 90698, 90700, 90701, 90702, 90720, 90721, DTaP-IPV Hemophilus influenza Type B Hep B/Hib Hepatitis A Gender if specified Frequency Comments Requires record review to determine Medical Necessity Covered when Medically Necessary during an outbreak of disease Series depends on combination four three series of two two Covered when Medically Necessary during an outbreak of disease Page 7 of 10

8 Hepatitis B, adolescent Hepatitis B, adult three three Hepatitis B, pediatric/adolescent three HPV (Human Papilloma Virus) bivalent Not covered Female HPV (Human Papilloma Virus) quadrivalent Both three 90655, 90657, 90685, Influenza mo to 35 mo annual 90656, 90658, 90686, Influenza annual 90662, Influenza, high dose annual Influenza, live attenuated annual Japanese Obsolete; quadrivalent is preferred encephalitis Not covered Travel vaccine Lyme Disease Meningococcal 90733, vaccine any 90704, 90705, 90707, 90708, series of MMRV and subsets two Oral polio Not covered Obsolete Plague Pneumococcal Conjugate 13 valent < 7 years series of four Covered when Medically Necessary during an outbreak of disease Covered when Medically Necessary during an outbreak of disease Pneumococcal Conjugate 7 valent < 6 years 13 valent is preferred Page 8 of 10

9 Pneumococcal polysaccharide (23 valent) two, at least five years apart Polio, inactivated total of four Rabies Rotarix (rotavirus) weeks to 8 months two Rotateq (rotavirus) weeks to 8 months Rubella TdaP > 6 Once 90703, Tetanus/Td Typhoid Unlisted vaccines three every 10 years two Recommended for all adults over age 64, and for high risk adults age Recommended for high risk children over age 2 who have completed the 13- valent pneumococcal series. Requires record review to determine Medical Necessity Maximum age for first dose is 14 weeks and 6 days Maximum age for first dose is 14 weeks and 6 days Covered when Medically Necessary during an outbreak of disease Requires record review to determine Medical Necessity Varicella Yellow fever Not covered Travel vaccine Zoster Once Application to Products This policy applies to ARBenefits. Consult ARBenefits Summary Plan Description (SPD) for additional information. Last modified by: SCS Date: 03/24/2014 Page 9 of 10

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