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Billing for flu vaccinations

Special circumstances not covered in the chart below:

  • Pre-authorization requirements for flu vaccines are waived for all members for out-of-network providers for the 2009-2010 flu season.
  • Self-funded plan coverage will vary by employer group, depending on purchase of coverage for immunizations, flu shots and pharmacy benefits. Self-funded plans may also place additional restrictions on member use of out-of-network providers.
  • Coinsurance and out-of-network benefits 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.

Key
  • VFC = Covered by Vaccines for Children program (you must use the VFC program for members under 19 years)
  • VFC only = NOT COVERED for adult Medicaid members
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Flu Shot Coverage by Plan   EFFECTIVE 10/1/2009 - 3/31/2010
Codes Description HMO/EPO, POS,
PPO, MIChild
(self-funded plans will
differ by employer)		 Medicaid Medicare
(all plans)
90655
Influenza virus vaccine, split virus, preservative free,
for children 6-35 months of age,
for intramuscular use		 Covered VFC only
Covered at $0 copay from in-network providers
90656
Influenza virus vaccine, split virus, preservative free,
for use in individuals 3 years and above,
for intramuscular use		 Covered
Adults:  Covered
Children: VFC		 Covered at $0 copay from in-network providers
90657
Influenza virus vaccine, split virus,
for children 6-35 months of age,
for intramuscular use		 Covered VFC only
Covered at $0 copay from in-network providers
90658
Influenza virus vaccine, split virus,
for use in individuals 3 years of age and above,
for intramuscular use		 Covered Adults: Covered
Children: VFC		 Covered at $0 copay from in-network providers
90660 Influenza virus vaccine, live,
for intranasal use
Ages 2-49 years only		 Covered VFC Covered at $0 copay from in-network providers
90663 Influenza virus vaccine, pandemic formulation, H1N1, $0 charge Covered Covered Covered but not preferred; use G9142
G9142 Influenza A (H1N1) vaccine, any route of administration, $0 charge Covered but not preferred; use 90663
Covered but not preferred; use 90663
Covered
Administration codes Description HMO/EPO, POS,
PPO, MIChild
(self-funded plans will
differ by employer)		 Medicaid Medicare
(all plans)
90465-90468; 90471-90474 CPT codes for vaccine administration.
Usually, an office copay does not apply if administration is the only service rendered.		 Covered Covered Not covered
G0008 CPT code for seasonal flu vaccine administration for Medicare patients.
Usually, an office copay does not apply if administration is the only service rendered.		 Not covered Not covered Covered
90470 (new H1N1 code) Preferred CPT code for H1N1 vaccine administration.
May also use 90465-90468; 90471-90474.
Usually, an office copay does not apply if administration is the only service rendered.		 Covered Covered Not covered
G9141 (new H1N1 code)
CPT code for H1N1 flu vaccine administration for Medicare patients.
Usually, an office copay does not apply if administration is the only service rendered.		 Covered
Covered
Covered


Seasonal Flu and h1n1 Flu vaccine coverage by LOCATION
Location
HMO or EPO POS PPO MIChild Medicaid Medicare

NOTE: Self-funded employers may customize these plans and not cover flu shots.


NOTE: If PriorityMedicare Rx (Part D) is a member's only plan with us, they don't have vaccine coverage.
Physician office Covered when given at any office, in or out of our network. Covered when given at any office, in or out of our network:
  • Preferred benefit level when given by in-network providers
  • Alternate benefit level for out-of-network providers
 Covered when given at any office, in or out of our network:
  • In-network benefit level when given by in-network providers
  • Out-of-network benefit level for out-of-network providers
 Covered when given at any office, in or out of our network. Covered when given at any office, in or out of our network. Covered when given at any office, in or out of our network.
Community clinics Covered, except for intranasal vaccine

If the health care organization contracts with Priority Health, it
must bill us directly. Member cannot file a claim form for reimbursement.

If the organization does not contract with Priority Health, it can bill us or the member can file a claim form for reimbursement.

Covered, except for intranasal vaccine

If the health care organization contracts with Priority Health it must bill us directly. Member cannot file a claim form for reimbursement. Preferred benefit level applies.

If the organization does not contract with Priority Health, it can bill us or the member can file a claim form for reimbursement. Alternate benefit level applies.

Covered, except for intranasal vaccine

If the health care organization contracts with Priority Health it must bill us directly. Member cannot file a claim form for reimbursement. In-network benefit level applies.

If the health care organization contracts with Priority Health, it can bill us or the member can file a claim form for reimbursement. Out-of-network benefit level applies.		 Covered, except for intranasal vaccine

If the health care organization contracts with Priority Health, it
must bill us directly. Member cannot file a claim form for reimbursement.

If the organization does not contract with Priority Health, it can bill us or the member can file a claim form for reimbursement.		 Covered for adults only

If the health care organization contracts with Priority Health, it must bill us directly. Member cannot file a claim form for reimbursement.

If the organization does not contract with Priority Health, it can bill us or the member can file a claim form for reimbursement.		 Covered at $0 copay

If the health care organization contracts with Priority Health, it must bill us directly. Member cannot file a claim form for reimbursement.

If the organization does not contract with Priority Health, it can bill us or the member can file a claim form for reimbursement.
  • Through 12/31/2009, the out-of-network deductible and benefit level applies.
  • Beginning 1/1/2010, there will be no difference in benefit level.
Home health care services All plans: Covered if the health care organization contracts with us and bills us directly.   The cost for administration is included in the cost of the nursing visit.
Health departments Covered

If the department contracts with Priority Health, it must bill us directly. Member cannot file a claim form for reimbursement.

If the department does not contract with Priority Health:
  • It must bill us for H1N1 vaccine administration.
  • It may bill us, or the member can file a claim form for reimbursement for, a seasonal flu vaccination.
 Covered

If the department contracts with Priority Health, it must bill us directly. Member cannot file a claim form for reimbursement.

If the department does not contract with Priority Health:
  • It must bill us for H1N1 vaccine administration.
  • It may bill us, or the member can file a claim form for reimbursement for, a seasonal flu vaccination.
  • Alternate benefit level applies.
Covered

If the department contracts with Priority Health, it must bill us directly. Member cannot file a claim form for reimbursement.

If the department does not contract with Priority Health:
  • It must bill us for H1N1 vaccine administration.
  • It may bill us, or the member can file a claim form for reimbursement for, a seasonal flu vaccination.
  • Out-of-network benefit level applies.
Covered

If the department contracts with Priority Health, it must bill us directly. Member cannot file a claim form for reimbursement.

If the department does not contract with Priority Health:
  • It must bill us for H1N1 vaccine administration.
  • It may bill us, or the member can file a claim form for reimbursement for, a seasonal flu vaccination.
 Covered

If the department contracts with Priority Health, it must bill us directly. Member cannot file a claim form for reimbursement.

If the department does not contract with Priority Health, it must bill us directly.		 Covered

All health departments are considered out-of-network, so the out-of-network deductible and benefits apply.

Member can file a claim form for reimbursement.
Pharmacies that participate in the Argus Vaccine Network Covered if the member has our prescription drug plan. Pharmacy will bill us directly. Covered if the member has our prescription drug plan. Pharmacy will bill us directly. Covered if the member has our prescription drug plan. Pharmacy will bill us directly. Covered for H1N1 flu vaccine only. Covered for H1N1 flu vaccine only
Part B benefit covered. Pharmacy will bill us directly.

Not covered for members with Part D (drug coverage) only.
Pharmacies that don't participate in the Argus Vaccine Network Member can file a claim form for reimbursement. Member can file a claim form for reimbursement. Member can file a claim form for reimbursement. Member can file a claim form for reimbursement. Covered for H1N1 flu vaccine only
Out-of-network benefits apply; member can file a claim form for reimbursement.
Urgent care centers Covered

If the center contracts with Priority Health, it must bill us directly. Member cannot file a claim form for reimbursement.

If the center does not contract with Priority Health, the member can file a claim form for reimbursement.

Urgent care copay will not apply if only service is flu vaccine.		 Covered

If the center contracts with Priority Health, it must bill us directly. Member cannot file a claim form for reimbursement.

If the center does not contract with Priority Health, the member can file a claim form for reimbursement. Alternate benefit level applies.

Urgent care copay will not apply if only service is flu vaccine.		 Covered

If the center contracts with Priority Health, it must bill us directly. Member cannot file a claim form for reimbursement.

If the center does not contract with Priority Health, the member can file a claim form for reimbursement. Out-of-network benefit level applies.

Urgent care copay will not apply if only service is flu vaccine.		 Covered

If the center contracts with Priority Health, it must bill us directly. Member cannot file a claim form for reimbursement.

If the center does not contract with Priority Health, the member can file a claim form for reimbursement.

Urgent care copay will not apply if only service is flu vaccine.		 Covered  for adults only.

If the center contracts with Priority Health, it must bill us directly. Member cannot file a claim form for reimbursement.

If the center does not contract with Priority Health, it can bill us or the member can file a claim form for reimbursement.

Urgent care copay will not apply if only service is flu vaccine.		 Covered at $0 copay

If the center contracts with Priority Health, it must bill us directly. Member cannot file a claim form for reimbursement.

If the center does not contract with Priority Health, the member can file a claim form for reimbursement.
Work site flu clinic Covered if the health care organization contracts with Priority Health and bills us directly; member cannot file a claim form for reimbursement.

Not covered if the employer has arranged a discount with the health care organization (even if contracted) and the organization will not bill us directly; member cannot file a claim form for reimbursement.		 Covered if the health care organization contracts with Priority Health and bills us directly; member cannot file a claim form for reimbursement.

Not covered if the employer has arranged a discount with the health care organization (even if contracted) and the organization will not bill us directly; member cannot file a claim form for reimbursement.		 Covered if the health care organization contracts with Priority Health and bills us directly; member cannot file a claim form for reimbursement.

Not covered if the employer has arranged a discount with the health care organization (even if contracted) and the organization will not bill us directly; member cannot file a claim form for reimbursement.		 Covered if the health care organization contracts with Priority Health and bills us directly; member cannot file a claim form for reimbursement.

Not covered if the employer has arranged a discount with the health care organization (even if contracted) and the organization will not bill us directly; member cannot file a claim form for reimbursement.		 Covered if the health care organization contracts with Priority Health and bills us directly; member cannot file a claim form for reimbursement.

Not covered if the employer has arranged a discount with the health care organization (even if contracted) and the organization will not bill us directly; member cannot file a claim form for reimbursement.		 Not applicable


Last modified 10/29/09