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Discuss routine preventive immunizations with your patients at their wellness visits

January 28, 2013

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Routine immunizations are considered preventive and therefore are covered in full for commercial AmeriHealth members under the medical benefit. We encourage you to discuss the following immunizations — as recommended by the Advisory Committee on Immunization Practices (ACIP) — with your patients during their wellness visits.

Immunization

Coverage

Hepatitis B virus (HBV)

  • Nonimmune individuals requesting protection from HBV infection

Diphtheria, tetanus, and pertussis (Dtap)/Tetanus, diphtheria, and pertussis (Tdap)

  • One-time dose for adults ages 19 through 64 who have not received Tdap previously or who lack evidence of immunity
  • Booster vaccination covered for adults and adolescents (any age) who have, or anticipate having, close contact with an infant younger than 12 months, who previously have not received Tdap?
  • Booster vaccination for pregnant women after 20 weeks gestation who previously have not received Tdap; if not vaccinated during pregnancy, Tdap should be administered immediately postpartum
  • One-time dose of Tdap for adults ages 65 and older without a risk indicator

Tetanus, Diphtheria (Td)

  • Booster vaccination once every ten years for adults ages 19 and older

Pneumococcal (PPSV23)*

  • One dose of PPSV23 vaccination for nonimmune adults ages 65 years and older
  • A second dose of PPSV23 for adults ages 65 and older if it has been five or more years since their first dose, or if received before turning 65
  • PPSV23 vaccination (first and second dose) for individuals ages 19 through 64 who have underlying medical conditions (e.g., chronic lung disease, chronic cardiovascular diseases, diabetes mellitus, cirrhosis, alcoholism, functional or anatomic asplenia, cochlear implants, cerebrospinal fluid leaks, chronic renal failure, nephrotic syndrome, HIV/AIDS, lymphoma, leukemia, Hodgkin's disease, organ or bone marrow transplant, taking immunosuppressive drugs)?
  • PPSV23 vaccination for adults ages 19 through 64 who smoke
  • PPSV23 vaccination for adults ages 19 through 64 who have asthma
  • PPSV23 vaccination for American Indians, Alaska Natives, and individuals ages
    50 through 64 who live in areas where the risk for invasive pneumococcal disease
    is increased
  • PPSV23 vaccination for American Indians, Alaska Natives, and individuals younger than 65 who have underlying medical conditions

Note: The recent change in ACIP recommendations regarding PCV13 for individuals ages 19 and older who have risk factors and have not received PCV13 or PPSV23, and for individuals ages 19 years and older with specified risk factors who have previously received one or more doses of PPSV23, is currently under review.

Influenza

  • Annual influenza vaccination for individuals ages 6 months and older (two-dose regimen for first-time influenza vaccination recipients ages 6 months through 8 years)?
  • Annual influenza vaccination with trivalent inactivated influenza vaccine (TIV) for adults ages 50 and older
  • Annual influenza vaccination with live attenuated influenza vaccine (LAIV) for healthy, non-pregnant individuals ages 2 through 49 years?

Varicella

  • A two-dose regimen of single-antigen varicella vaccination for unvaccinated adults who lack evidence of varicella immunity
  • A second dose of single-antigen varicella vaccination for nonimmune adults with incomplete varicella vaccination

Zoster

  • Nonimmune individuals ages 60 and older who have not received the varicella vaccine

Human papillomavirus (HPV4 or HPV2)*

  • Three-dose regimen of quadrivalent human papillomavirus (HPV4 [types 6, 11, 16, and18]) vaccination for individuals ages 9 through 26?
  • Three-dose regimen of bivalent human papillomavirus (HPV2 [types 16 and 18]) vaccination for females ages 9 through 26?
  • Catch-up vaccination for females ages 13 through 26 who have not been
    vaccinated previously or who have not completed the three-dose series. If a female reaches age 26 before the vaccination series is complete, remaining doses can be administered after age 26.?
  • Routine three-dose regimen of HPV4 for males ages 9 through 12?
  • Catch-up vaccination for males ages 13 through 21 who have not been vaccinated previously or who have not completed the three-dose series?
  • Males in a defined risk group for human papillomavirus (i.e., immunocompromised, HIV infection, MSM); the remaining doses can be administered from ages 22 through 26

Haemophilus influenza
type B (Hib)

  • Adults with specific health conditions that may affect immune system

Polio*

  • Three-dose primary vaccination series for unvaccinated adults who are at increased risk
  • Catch-up for under-vaccinated adults who are at risk

Measles, mumps, rubella (MMR)*

  • A two-dose regimen of MMR vaccination for nonimmune adults at risk for measles and mumps infection
  • One dose of MMR vaccination for individuals who lack evidence of rubella immunity

Hepatitis A virus (HAV)*

  • Nonimmune individuals at risk for HAV infection

Meningococcal (MCV4, MCV4-CRM, MPSV4)*

  • One-dose regimen of meningococcal conjugate vaccine (MCV4, MCV4-CRM) for unvaccinated individuals ages 16 through 21; no booster dose needed?
  • Booster vaccination five years after the initial dose for individuals with an increased risk for meningococcal disease, then every five years if individual remains at increased risk
  • Individuals ages 19 through 55 who are at increased risk may elect to receive the two-dose regimen for vaccination. In this case, the initial booster is covered three years after completion of the vaccination regimen, then a booster every five years if individual remains at increased risk.
  • One-dose meningococcal polysaccharide vaccine (MPSV4) for nonimmune individuals ages 56 and older with an increased risk of meningococcal disease, with a booster dose every five years if individual remains at risk

*Denotes coverage for at-risk population
?ACIP recommendations for this immunization overlap the pediatric and adult populations

The coverage information included in this table applies to commercial AmeriHealth members. For more information about immunization coverage for Medicare Advantage HMO members, please refer to the article in the November 2012 edition of Partners in Health UpdateSM: Vaccination coverage for Medicare Advantage HMO members.

Note: AmeriHealth continually reviews coverage for immunizations benefits. Coverage may change according to ACIP recommendations.

This is not a statement of benefits. Benefits may vary based on state requirements, Benefits Program (HMO, PPO, etc.), and/or employer groups. Providers should call Customer Service for the member's applicable benefits information. Members should be instructed to call the Customer Service telephone number listed on their ID card.

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