Immunization Coverage Issues

Per the Affordable Care Act, insurance companies must pay in the full costs of FDA-approved immunizations that are medically indicated.

Unfortunately, these companies often play dishonest games in this area.

The immunizations include, but are not limited to:

•HPV (Gardasil 9, CPT Code 90651) from age 9 to 45, total 3 shots

The FDA announced 10/5/18 that this vaccine coverage has been expanded for all at-risk individuals up to and including age 45. This includes all adults up to age 45.

https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm622715.htm

•Hepatitis A (CPT Code 90632) and/or Hepatitis B (CPT Code 90746), or combined Hepatitis A/B (CPT Code 90636) for Men who have sex with Men, total 2 or 3 shots

https://www.cdc.gov/hepatitis/populations/msm.htm

• Meningitis (Menactra, CPT Code 90734) for Men who have sex with Men:

https://www.health.ny.gov/diseases/aids/general/prep/docs/health_advisory_10-2016.pdf

• Other routine immunizations (TDAP, MMR, Influenza, etc).

Insurance companies routinely reject covering vaccines, which is wrong on many levels. As the financial transactions and communication between you and the insurance company are not under our control, you must deal with these companies directly. We have no influence over them.

These companies and their staff are often woefully uninformed (or at least claim to be) regarding standard care in this area, and routinely deny coverage. You must self-advocate, call them on their mistakes, and ensure they pay honestly. If they don’t pay, you must report them to NY State Department of insurance (https://www.dfs.ny.gov/consumer/fileacomplaint.htm)

Steps to follow:

  1. Call your insurance company to confirm coverage of the immunization in question (e.g. HPV (brand name Gardasil 9, CPT Code 90651). CPT codes are listed above. Tell them that your doctor is out-of-network, that your doctor states you need the immunization course, and you will be given the immunization in his office, be charged by the office, and then you will submit a letter to insurance for reimbursement.

  2. If they say no, push back using the language in italics above.

  3. If they still say no, request the immunization be covered if the doctor sends a prescription for immunization to a local pharmacy, and you pick it up there. If they say yes, then please contact our office. We’ll send in a prescription to your local pharmacy, the pharmacy will order it, and the pharmacy will get it in a few days. When it arrives at the pharmacy, you will pick it up at the pharmacy, keep it refrigerated, then bring to our office where the doctor will administer the vaccine. Note: pharmacies are often disorganized, and you must be in close contact with them to ensure things go smoothly.

If the insurance company is flat-out refusing,you should appeal in writing. Please see below for a sample letter.

Sample Appeal Letter 

Immunization Coverage Complaint

Today’s Date:

Member Name:

Member Date of Birth:

Member Insurance ID:

Dear Insurance Company,

Regarding:

Immunization Name(s):

Medically indicated Immunizations and Preventive services must be covered by insurance 100% according to rules and regulations set forth by the Affordable Care Act. My doctor states I need the above immunization course(s). If you do not confirm in writing within five days that the above immunization will be covered in full according to ACA guidelines, I will submit a complaint with the NY State Dept. of Insurance.

Optional for HPV: The FDA announced 10/5/18 that the HPV vaccine (brand name Gardasil-9, CPT code 90651)coverage has been expanded for all at-risk individuals up to and including age 45.

•https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm622715.htm

Optional:. Per the US CDC (Center for Disease Control), for Men who have sex with Men, these immunizations include Hepatitis A (CPT Code 90632), Hepatitis B (CPT Code 90746), HPV (CPT Code 90651), Meningitis (CPT Code 90734), and others:

•https://www.cdc.gov/hepatitis/populations/msm.htm

•https://www.health.ny.gov/diseases/aids/general/prep/docs/health_advisory_10-2016.pdf

If this issue it not addressed within 5 business days, I will submit a letter of complaint to the New York State Department of Insurance within 10 business days from the date of this letter.  

Sincerely,

Patient name

Patient address

Patient phone number

Please reach out to our office if you have any questions.