Coverage Explanation

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.