Flu Benefit and Vaccine Recommendations

Date: 10/17/17

As a reminder, the optimal time to receive the influenza vaccine is as early in the season as it is available and preferably by the end of October. The flu vaccine is a benefit of Texas Medicaid and is available to Superior members at no cost.

The benefit is available through network medical providers or participating network pharmacy providers who have signed an addendum to administer flu vaccines. Medicaid members 18 years and older and CHIP Perinate mothers have the option to obtain their vaccine at a participating pharmacy. 

Coverage for the flu vaccine is National Drug Code (NDC) specific. Guidance is provided by Texas Health and Human Services (HHS) as to which NDCs are reimbursable. The covered NDCs are coded with the Pharmacy Benefit Manager (PBM) to permit the adult pharmacy flu vaccine claims to adjudicate to the correct products at the pharmacy. To see a full list of the covered NDCs for the flu, please download the Season Flu Vaccine NDC-to-Procedure Code Crosswalk.

Please note: Not all influenza products are covered by Texas Medicaid.

Influenza Vaccine Recommendations:

The Center for Disease Control (CDC) recommends the flu vaccination for the following high-risk groups and their contacts and caregivers:

• Children aged 6-59 months
• Adults aged ≥ 50 years
• Members with chronic pulmonary (including asthma), cardiovascular (except isolated hypertension), renal, hepatic, neurologic, hematologic, or metabolic disorders (including diabetes mellitus)
• Members who are immunocompromised due to any cause (including medications or HIV infection)
• Women who are, or will be, pregnant during the influenza season
• Children and adolescents (aged 6 months through 18 years) receiving aspirin or salicylate-containing medications and who might be at risk for Reye syndrome
• Residents of nursing homes and other long-term care facilities
• American Indians/Alaska Natives
• Members who are extremely obese (BMI ≥40)
• Caregivers and contacts of those at risk
• Health-care personnel in inpatient and outpatient care settings, medical emergency-response workers, employees of nursing home and long-term care facilities who have contact with patients or residents, and students in these professions who will have contact with patients
• Household contacts and caregivers of children aged ≤59 months (i.e., <5 years), particularly contacts of children aged <6 months and adults aged ≥50 years
• Household contacts and caregivers of persons who are in one of the high-risk categories listed.

The influenza vaccine should be administered annually to all children beginning at the age of 6 months. Children age 6 months through 8 years who have had two doses of trivalent of quadrivalent vaccine require only 1 dose. Otherwise these children will need 2 doses of influenza vaccine separated by at least 4 weeks.

Please note: Live-Attenuated Influenza Vaccine (LAIV) is not recommended for use in any population for 2017-18. per the CDC.

Billing Codes

The following are approved influenza codes:

90630	90657	90672	90686
90653	90658	90673	90687
90654	90660	90674	90688
90655	90661	90682
90656	90662	90685

The appropriate codes for flu vaccine administration are:

90460	90472
90461	90473
90471	90474

Please note: Hospital-based Rural Health Clinics (RHC) must submit claims for pneumococcal and influenza vaccines as non-RHC services, under their hospital provider identifier.

For additional information, please contact Provider Services at 1-877-391-5921.