QUEST Integration – Immunizations

Original Effective Date:

08/01/1994

Current Effective Date:

12/15/2020

HMSA immunization is in accordance with the recommendations of the Advisory Committee on Immunization Practices (ACIP).

ACIP Recommendations

The Advisory Committee on Immunization Practices (ACIP) develops vaccine recommendations for children and adults. The recommendations include the age(s) when the vaccine should be given, the number of doses needed, the amount of time between doses, and precautions and contraindications.

All of the ACIP’s recommendations are posted on the Centers of Disease Control and Prevention (CDC) webpage at: https://www.cdc.gov/vaccines/hcp/acip-recs/.

All routine childhood immunizations are covered. The Department of Health’s Vaccines for Children Program provides the injectable materials, at no cost, to enrolled physicians and clinics to immunize children through the age of 18 years. Therefore, the injectable materials that are available through the Department of Health’s Vaccines for Children Program are not payable by QUEST Integration. If immunizations are given as part of an EPSDT screening examination or catch-up screening, the administration is paid as part of the EPSDT global fee and not reimbursed separately. For patients age 19 and older who are not part of the VFC program, the cost of the injectable materials is payable by QUEST Integration when billed using the NDC number.

Routine immunizations for children include:

• Hep B
• DTaP
• DT
• Hemophilus influenzae type B (Hib)
• Inactivated Polio Vaccine (IPV)
• MMR
• Varicella (chicken pox)
• Pneumococcal conjugate
• Td
• Human Papillomavirus (HPV)
• Rotavirus

The following non-routine immunizations also are covered:

• Hep A for children living in communities with high rate of Hep A and periodic outbreaks of Hep A
• Flu shots. CDC recommends a yearly flu vaccine for everyone ages six months and older
• Pneumococcal polysaccharide (23 Valent for children with functional and anatomical asplenia, immunocompromising illness or medications, chronic illness (as above), Alaskan native or American Indian, or those who have received a bone marrow transplant)

Vaccinations for adults are covered. These include but are not limited to:

• Pneumococcus
• Tetanus
• Diphtheria
• Pertussis
• Varicella
• Measles, mumps and rubella (up to age 49)
• Influenza
• Hepatitis A for individuals at high risk due to sexual practices, drug use, clotting factor disorders, chronic liver disease, etc.
• Hepatitis B when high-risk criteria is met:
• Healthcare personnel who may be exposed via blood or patient specimens
• Intimate contacts of persons with persistent hepatitis B (carriers)
• Populations with high incidence of the disease (e.g., Alaskan Eskimo, South East Asian or Haitian immigrants)
• Persons at increased risk due to sexual practices
• Human Papillomavirus (HPV) (through age 45)

Vaccinations for travel purposes are not covered.

During the COVID-19 Public Health Emergency, vaccinations for COVID-19 were funded by the federal government and do not need to be billed to HMSA. HMSA reimbursed providers for the vaccine administration codes only.

With the end of COVID-19 Public Health Emergency on May 11,2023, HMSA started to cover COVID-19 vaccines and vaccine administration codes as part of the health plan benefits. Below is a list of COVID-19 vaccines and the vaccine administration codes. Coverage will begin on the day the Advisory Committee on Immunization Practices (ACIP) approves the use of the vaccine.

The original monovalent vaccines’ emergency use authorization (EUA) has been rescinded and those vaccines are no longer recommended for use, effective November 1, 2023.

EPSDT Clinical Information Form Requirement

Childhood immunizations provided as part of an EPSDT screening exam must be recorded on the EPSDT clinical information form. If a scheduled immunization is not given, the reason for not giving the immunization must be provided on the form. See QUEST Integration – Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services for details.

Revision History