Routine immunizations are considered preventive and therefore are covered with
no cost-sharing (i.e., copayments, coinsurance, and deductibles) when received
from a participating provider for commercial IBC 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 IBC
members. Vaccination coverage for Medicare Advantage HMO and PPO members will
vary by plan. Medicare Advantage HMO and PPO members should review their
Evidence of Coverage for information on preventive care and immunization
coverage.
Note: IBC 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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