CurrentOklahoma Health Care AuthorityPolicy N/A

Flu Vaccine Coverage

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This document governs SoonerCare coverage, administration, reimbursement, and covered NDCs for influenza vaccines, including pharmacy and medical-benefit access by member age and pharmacy administration payment limits.

Policy Summary

PayerOklahoma Health Care Authority

PolicyFlu Vaccine Coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSeptember 5, 2017

Next Review DateN/A

Key ActionDirect members age 18 and younger to receive influenza vaccination at a physician's office through the Vaccines for Children Program.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

19+Age eligible through both benefits

18 and youngerPrescription benefit exclusion

$0Pharmacy vaccine copay

0Additional administration fees compensable

2017-2018Covered vaccine season

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CurrentOklahoma Health Care AuthorityPolicy N/A

Flu Vaccine Coverage

Customize your policy alerts

Sign up for all Oklahoma Health Care Authority policy alerts

Know when Oklahoma Health Care Authority releases new policies or updates existing guidance.

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Policy Summary

PayerOklahoma Health Care Authority

PolicyFlu Vaccine Coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSeptember 5, 2017

Next Review DateN/A

Key ActionDirect members age 18 and younger to receive influenza vaccination at a physician's office through the Vaccines for Children Program.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

19+Age eligible through both benefits

18 and youngerPrescription benefit exclusion

$0Pharmacy vaccine copay

0Additional administration fees compensable

2017-2018Covered vaccine season

Flu Vaccine Coverage Criteria

Members age 19 and older

Covered through both the SoonerCare prescription drug benefit and medical benefit when the member is age 19 or older.

Adult member coverage: Member is age 19 or older.age >= 19 years

Flu vaccine access is available through both the SoonerCare prescription drug benefit and the medical benefit.

Members age 18 and younger

For members age 18 and younger, vaccination should occur at a physician's office through the federal Vaccines for Children Program.

Younger member vaccination pathway: Member is age 18 or younger.age <= 18 years

The prescription drug benefit does not cover the flu vaccine for this age group; the member should receive vaccination at a physician's office through the federal Vaccines for Children Program.

For members age 18 and younger, flu vaccines are not covered through the SoonerCare prescription drug benefit. These members should receive vaccination at a physician’s office through the federal Vaccines for Children Program.

Additional administration fees for flu vaccines administered by pharmacies are not compensable. Pharmacies are reimbursed the allowable vaccine cost and the standard prescription dispensing fee.

Covered Vaccine NDCs

Covered NDCsNDCCovered

19515-0896-01	Brand Name = FLULAVAL QUAD 2017-2018
49281-0417-10	Brand Name = FLUZONE QUAD 2017-2018
19515-0896-11	Brand Name = FLULAVAL QUAD 2017-2018
49281-0417-50	Brand Name = FLUZONE QUAD 2017-2018
19515-0912-41	Brand Name = FLULAVAL QUAD 2017-2018
49281-0417-58	Brand Name = FLUZONE QUAD 2017-2018
19515-0912-52	Brand Name = FLULAVAL QUAD 2017-2018
49281-0417-88	Brand Name = FLUZONE QUAD 2017-2018
33332-0017-01	Brand Name = AFLURIA 2017-2018
49281-0627-15	Brand Name = FLUZONE QUAD 2017-2018

1–10 of 36

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Provider and Pharmacy Billing Rules

Billing Rule

Pharmacy Benefit Age Restriction

For members age 18 and younger, flu vaccines are not covered through the SoonerCare prescription drug benefit. Direct these members to a physician's office for vaccination through the federal Vaccines for Children Program.

Members age 19 and older may receive flu vaccines through both the SoonerCare prescription drug benefit and the medical benefit.

Billing Rule

Additional Administration Fee Not Payable

Pharmacies administering flu vaccines are reimbursed the allowable cost of the vaccine and the standard prescription dispensing fee. Do not bill or expect payment for an additional pharmacy flu-vaccine administration fee.

Flu vaccines administered by pharmacies do not count against a member's monthly prescription limit.
Members have no copay for the flu vaccine.

Policy Background

This policy describes seasonal influenza vaccine access for SoonerCare members through the medical and prescription drug benefits. Members age 19 and older may receive flu vaccines through both benefits, while members age 18 and younger should be vaccinated at a physician’s office through the federal Vaccines for Children Program. The policy also establishes pharmacy reimbursement limits, including no member copay and no compensation for additional administration fees.

Program Reference

Vaccines for Children Program

ProgramVaccines for Children Program

Eligible membersMembers age 18 and younger

Vaccination settingPhysician's office