Special circumstances not covered in the chart below:
- No authorization is required for in-network providers and PPO providers.
- Self-funded plan coverage will vary by employer group, depending on purchase of immunization and/or flu shot coverage.
- Coinsurance may apply.
- Vaccine shortages: In the event of a vaccine shortage, Priority Health may make exceptions
to the coverages listed here; we will issue written guidelines in that case
and post them on this website. Note: A shortage is not the same as a
delay from your vendor.
- Employer-required vaccinations: Priority Health does not cover any vaccine required for employment
(e.g., for health care workers).
Key
- GL = Recommended in the Preventive Health Care Guidelines;
patient's deductible (if applicable) will be waived. Deductible will apply for vaccines not listed in the guidelines.
- VFC = Covered by Vaccines for Children program (you must use the VFC program for members under 19
years)
Jump down to Coverage by location
Flu Shot Coverage by Plan
|
| Codes |
Description |
HMO/EPO,
POS,
PPO, MIChild
(self-funded plans will
differ by employer) |
Medicaid |
Medicare
(all plans) |
90655 GL
|
Influenza virus vaccine, split virus, preservative free,
for children 6-35 months of age,
for intramuscular use |
Covered |
VFC |
Not covered |
| 90656 GL |
Influenza virus vaccine, split virus, preservative free,
for use in individuals 3 years and above,
for intramuscular use |
Covered
|
Adults: Covered
Children: VFC |
Covered |
| 90657 GL |
Influenza virus vaccine, split virus,
for children 6-35 months of age,
for intramuscular use |
Covered |
VFC |
Covered |
| 90658 GL |
Influenza virus vaccine, split virus,
for use in individuals 3 years of age and above,
for intramuscular use |
Covered |
Adults: Covered
Children: VFC |
Covered |
| 90660 GL |
Influenza virus vaccine, live,
for intranasal use
Ages 2-49 years only |
Covered |
VFC |
Covered |
| Administration |
CPT codes to use for vaccine administration.
Usually, an office copay does not apply if
administration is the only service rendered. |
90465-90474 |
90465-90474 |
G0008 |
| Diagnosis |
Diagnosis codes:
Use V06.6 when billing combination influenza/pneumococcal vaccines.
|
V04.8
V06.6
V06.8
V70.0 |
V04.8
V06.6
V06.8
V70.0 |
N/A |
| Coverage by Location |
| Location |
Fully funded plans; MIChild
|
Self-funded
plans
Employers may customize these plans and not cover flu shots. |
Medicaid
|
Medicare
(all plans) |
| Physician office |
HMO: Covered for in-network providers
POS: Covered at Preferred benefit level for in-network providers and at
Alternate benefit level for out-of-network providers
PPO: Covered at In-Network level for in-network providers and at
Out-of-Network level for out-of-network providers
MIChild: Covered for in-network providers |
EPO: Covered for in-network providers only
POS: Same as fully funded
PPO: Same as fully funded |
Covered |
Covered |
| Home health care (includes community clinics) |
- Covered if contracted with Priority Health and billed directly
- Intranasal vaccine not covered
- Administration charge included with nursing visit
|
- Covered if contracted with Priority Health and billed directly
- Intranasal vaccine not covered
- Administration charge included with nursing visit
|
- Covered for adults only if contracted with Priority Health and billed directly
- Administration charge included with nursing visit
|
- Covered if contracted with Priority Health and billed directly (In-network)
|
| Health departments |
Not covered |
Not covered |
VFC (children) |
Not covered |
Last modified
11/12/08
|
