Routine immunizations are considered preventive and therefore are covered with no cost-sharing (i.e., copayment, coinsurance, and deductible) when received from a participating provider 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. The coverage information included in the table below applies to commercial AmeriHealth members. Vaccination coverage for Medicare Advantage HMO members will vary by plan. Medicare Advantage HMO members should review their Evidence of Coverage for information on preventive care and immunization coverage. 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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Immunization Coverage Hepatitis B virus (HBV)

Routine vaccination for infants birth through 18 months;

Catch-up vaccination for children through age 18;

Routine vaccination for adults ages 19 through 59 with diabetes mellitus who have not been vaccinated previously;

Nonimmune individuals requesting protection from HBV infection. Diphtheria, tetanus, and pertussis (DTaP)/Tetanus, diphtheria, and pertussis (Tdap)

Routine DTaP vaccination regimen for children ages 2 months through 6 years;

Catch-up vaccination up to age 7;

One dose Tdap for under-vaccinated children ages 7 through 10 years;

One dose of Tdap for adolescents ages 11 through 18 who have completed the childhood DTaP vaccination series;

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 during each pregnancy regardless of number of years since prior Td or Tdap vaccination (preferred administration is between 27?36 weeks gestation);

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 (PCV13; PPSV23)*

Routine PCV13 vaccination for infants ages 2 through 15 months (first dose can be administered as early as 6 weeks);

Catch-up PCV13 vaccination to age 5;

PCV13 vaccination for children ages 2 through 6 with certain medical conditions (see ACIP immunization schedule);

One dose of PCV13 for unvaccinated individuals ages 19 years or older who have specific health conditions that affect the immune system;

individuals should receive one dose of PCV13 followed by one dose of PPSV23 at least 8 weeks later;

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 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.

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 inactivated influenza vaccine (IIV) for adults ages 50 and older;

Annual influenza vaccination with live attenuated influenza vaccine (LAIV) or inactivated influenza vaccine (IIV) for healthy, non-pregnant individuals ages 2 through 49 years.

Varicella

Routine vaccination or combination vaccination (measles, mumps, rubella, and varicella or MMRV) for children ages 12 months through 6 years;

Catch-up vaccination for children and adolescents up to age 12;

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, HPV2)*

Three-dose regimen of quadrivalent human papillomavirus (HPV4 [types 6, 11, 16, and 18]) vaccination for individuals ages 9 through 26;

Three-dose regimen of bivalent human papillomavirus (HPV2 [types 16 and 18]) vaccination for females ages 11 through 26;

first dose can be given at age 9;

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 either HPV2 or HPV4 for females ages 11 or 12;

Routine three-dose regimen of HPV4 for males ages 11 or 12;

first dose can be give at age 9;

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)*

Routine vaccination for infants ages 2 through 6 months, with booster vaccination ages 12 through 15 months;

Catch up vaccination for children up to age 5;

Individuals with specific health conditions that may affect the immune system.

Polio*

Routine vaccination infants and children ages 2 months through 6 years;

Catch-up vaccination for children and adolescents up to 18 years;

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)*

Routine vaccination MMR or MMRV (measles, mumps, rubella, and varicella) for children ages 12 months through 6 years;

Catch-up vaccination for children and adolescents up to age 12;

Vaccination for certain high-risk groups (see ACIP recommendations);

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)*

Routine two-dose regimen for childhood vaccination;

first dose between ages 12 through 23 months, and second dose 6 to 18 months after the first;

Catch-up vaccination for children and adolescents up to age 18;

Nonimmune individuals at risk for HAV infection.

Meningococcal (MCV4, MCV4-CRM, MPSV4)*

Routine one-dose regimen of meningococcal vaccination for adolescents ages 11 or 12, with a one-time booster at age 16;

One-dose regimen for first-year college students up through age 21 who are living in residence halls if they have not received the booster vaccination at ages 16 or older;

One-dose regimen for nonimmune individuals ages 2 through 55 with an increased risk for meningococcal disease, then every 5 years if individual remains at increased risk;

Two-dose regimen for 3 months apart of MCV4 for infants and toddlers ages 9 through 23 months at increased risk for invasive meningococcal disease;

initial booster 3 years after completion of regimen; then booster vaccinations every 5 years;

Two-dose regimen for 3 months apart of MCV4 2 for individuals ages 2 through 55 at increased risk for invasive meningococcal disease;

ages 2 through 6 initial (first) booster 3 years after completion of regimen, ages 7 and older initial (first) booster 5 years after completion of regimen; then booster vaccinations every 5 years regardless of age if remains at risk. Rotavirus (RV5, RV1)

Three-dose regimen (RV5) for ages 2 through 6 months;

Two-dose regimen (RV1) for ages 2 through 4 months;

A total of three doses if prior vaccination included use of different or unknown rotavirus vaccine.

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