Coverage Explanation
Provider Type
- Physicians
- Participating Physician Groups (PPG)
For members covered by Medicare Part B or the medical benefit, covered immunizations include influenza, pneumococcal and hepatitis B, and other vaccines where the member is at risk.
All other immunizations are covered under Medicare Part D. If the member does not have Part D coverage, then other immunizations are not covered.
Specified immunizations are covered in all the following instances:
- Influenza and pneumococcal vaccines: In accordance with the federal regulations governing Medicare, members may self-refer for influenza and pneumococcal vaccines with no copayments. Participating providers should address the following items to help ensure compliance with this requirement:
- Allow self-referral within the Health Net Medicare Advantage (MA) network
- Participating providers that are unable to provide these vaccines should provide the member with a list of affiliated clinics
- Hepatitis B vaccines are covered for high and intermediate-risk groups only. If the condition does not fall into one of the categories listed below, the vaccine is not covered. No copayment applies if this is the only service provided:
- High-risk group:
- End-stage renal disease (ESRD) members
- Hemophiliacs receiving Factor VIII or IX concentrates
- Mentally handicapped, institutionalized residents
- Persons living in the same household as hepatitis B carriers
- Homosexual men
- Illicit drug users
- Intermediate-risk group:
- Staff in institutions for the mentally handicapped
- Health care staff who have contact with blood or blood-derived body fluids
Immunizations required for foreign travel or occupational-related requirements are not covered.
- High-risk group:
Zostavax
Health Net considers the herpes zoster vaccine (Zostavax®) medically necessary for the prevention of herpes zoster (shingles) in individuals ages 50 and older, in accordance with the recommendations of the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP).
The Centers for Medicare & Medicaid Services (CMS) considers Zostavax to be a Part D medication.
Part D Billing Options
Zostavax is administered in the provider's office. The following three procurement and billing options are currently available to providers.
Option One - Health Net's Preferred Option
Participating providers may request Zostavax by contacting Pharmacy Services. Health Net coordinates the delivery of the vaccine to the provider by Health Net's approved specialty pharmacy. The specialty pharmacy then charges Health Net and bills the member for their copayment or coinsurance, if applicable.
Option Two
With a prescription from the member's prescriber, the Health Net member may obtain Zostavax directly from a Health Net participating pharmacy, paying the applicable copayment or coinsurance. The member may take the vaccine back to their prescriber office for administration. The member must be informed that it is essential for the vaccine to remain frozen.
Option Three
The prescriber may obtain and administer Zostavax to the member and charge the member for the cost of the vaccine. The member may then submit a claim on a Health Net Medicare Prescription Claim form to Health Net for reimbursement for the cost of the medication, less the member's copayment or coinsurance (if applicable).