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    v1.0.30
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyOklahoma Health Care Authority Flu Coverage | Open…
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    CurrentOklahoma Health Care AuthorityPolicy N/A

    Flu Vaccine Coverage

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    Coverage of influenza vaccines for SoonerCare members by age and benefit, including pharmacy reimbursement and listed 2014–2015 influenza vaccine NDCs.

    Policy Summary
    PayerOklahoma Health Care Authority
    PolicyFlu Vaccine Coverage
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateSeptember 10, 2014
    Next Review DateN/A
    Key ActionDirect members age 18 and younger to receive influenza vaccination at a physician's office through the federal Vaccines for Children Program rather than billing the prescription drug benefit.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    19+Minimum age for coverage through both prescription drug and medical benefits
    18 and youngerAge group excluded from prescription drug benefit coverage
    2Benefits providing flu vaccine access
    0Additional pharmacy administration fee reimbursable
    12Listed 2014–2015 influenza vaccine NDCs

    Member Age and Benefit Coverage

    Member Age and Benefit Coverage

    Coverage depends on the member’s age and the benefit through which the influenza vaccine is provided.

    ALL of the following

    • Member is age 19 or older

      • Influenza vaccine is provided through the SoonerCare prescription drug benefitAge 19 or older

        Covered.

      • Influenza vaccine is provided through the medical benefitAge 19 or older

        Covered.

    Member is age 18 or younger
    Policy Summary
    PayerOklahoma Health Care Authority
    PolicyFlu Vaccine Coverage
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateSeptember 10, 2014
    Next Review DateN/A
    Key ActionDirect members age 18 and younger to receive influenza vaccination at a physician's office through the federal Vaccines for Children Program rather than billing the prescription drug benefit.
    SourceLink
    On This Page
    Member Age and Benefit CoverageVaccine Codes and Benefit ThresholdsVaccination Routing and ReimbursementBenefit and Program Definitions

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Influenza vaccine is not covered through the prescription drug benefit. The member should receive the vaccine at a physician’s office through the federal Vaccines for Children Program.

    Vaccine Codes and Benefit Thresholds

    Covered 2014–2015 Influenza Vaccine NDCsNDCCovered
    49281-0414-10Listed influenza vaccine NDC
    49281-0414-50Listed influenza vaccine NDC
    49281-0414-58Listed influenza vaccine NDC
    49281-0414-88Listed influenza vaccine NDC
    49281-0621-15Listed influenza vaccine NDC
    49281-0621-78Listed influenza vaccine NDC
    49281-0709-48Listed influenza vaccine NDC
    49281-0709-55Listed influenza vaccine NDC
    58160-0901-52Listed influenza vaccine NDC
    62577-0613-01Listed influenza vaccine NDC
    1–10 of 12
    1/2
    Flu vaccine coverage age threshold
    Minimum age19 years
    Prescription drug benefitFlu vaccines are available through the SoonerCare prescription drug benefit for members age 19 and older.
    Medical benefitFlu vaccines are available through the medical benefit for members age 19 and older.
    Prescription drug benefit age exclusion
    Excluded age groupMembers age 18 and younger
    Prescription drug benefit statusFlu vaccines are not covered through the prescription drug benefit for members age 18 and younger.
    Vaccination routeThese members should receive the vaccine at a physician's office through the federal Vaccines for Children Program.

    Vaccination Routing and Reimbursement

    Billing Rule

    Route pediatric vaccination through Vaccines for Children

    Direct members age 18 and younger to receive the influenza vaccine at a physician’s office through the federal Vaccines for Children Program. Do not bill the SoonerCare prescription drug benefit for these members.

    Billing Rule

    Submit pharmacy vaccine reimbursement

    For influenza vaccines administered by a pharmacy, bill the allowable cost of the vaccine and the standard prescription dispensing fee. Additional administration fees are not compensable.

    Benefit and Program Definitions

    SoonerCare prescription drug benefit
    BenefitSoonerCare prescription drug benefit
    Covered serviceEligible members may obtain influenza vaccines through this benefit.
    Pharmacy accessThe benefit includes pharmacy-dispensed influenza vaccines.
    Medical benefit
    BenefitMedical benefit
    Eligible membersMembers age 19 and older
    Covered serviceEligible members may receive influenza vaccines through the medical benefit outside the prescription drug benefit.
    Vaccines for Children Program
    ProgramFederal Vaccines for Children Program
    Applicable membersMembers age 18 and younger
    Administration locationA physician's office
    Vaccination routeMembers in this age group should receive influenza vaccination through the program.