Flu vaccines are covered under a member’s medical benefits unless they are a Mercy MedicareADVANTAGE member and then flu vaccines are covered under their Medicare Part B benefits.

We encourage our members to receive their seasonal flu vaccine from a participating provider.

Mercy MedicareADVANTAGE members and Missouri Consolidated Health Care Plan members can go in or out of the Mercy Health Plans provider network for their flu vaccines and we will pay up to the allowable amount based on their coverage.

We offer other options:

Mercy Health Plans members may visit one of the participating Flu Vaccine Clinics near them (below).

Or Mercy Health Plans members may pay for flu vaccination out of pocket at a non-participating clinic and submit this form for reimbursement up to $25.

Participating providers may submit a claim for the vaccine and administration fee.

Non participating providers may use this form.

Mercy Health Plans will cover the Influenza A (H1N1) vaccine administration cost using the code G9141. Since it is anticipated there will be no cost to provider for the Influenza A (H1N1) vaccines, there will be no reimbursement. However, we ask that providers submit a claim for the Influenza A (H1N1) vaccine using the code G9142 for tracking purposes.

If a member pays for the H1N1 vaccination out of pocket at a non-participating clinic, they can submit this form for reimbursement up to $20.

Mercy Health Plans covers FluMist for healthy non-pregnant members ages 2-49 years. Mercy Health Plans coverage for this vaccine is consistent with the current CDC and FDA guidelines.

Remember that there needs to be at least four weeks between the administration of the live attenuated influenza vaccine (LAIV) and the Influenza A (H1N1) vaccine.

Mercy Health Plans follows the 2009 Advisory Committee on Immunization Practices (ACIP) guidelines when determining benefits and reimbursement for the pneumococcal vaccine.

Mercy Health Plans (MHP) covers the Zostavax vaccine for all members age 60 years and older. Reimbursement depends upon the coverage plan of the member.

For Commercial Members:

Zostavax (CPT 90736) and its administration are covered when billed under the member’s medical benefit.

Zostavax is not covered under the pharmacy benefit for commercial or non-Medicare members.

However, if a member does pay cash for the vaccination at the pharmacy and submits the receipt to MHP’s Pharmacy Department, the member will be reimbursed.

You may order Zostavax from CuraScript Specialty Pharmacy and request its shipment to your office for administration by completing the CuraScript Enrollment form at mercyhealthplans.com or contacting CuraScript at 1-888-773-7376.CuraScript will bill MHP under the member’s medical benefit.

For Medicare Members (Mercy MedicareADVANTAGE)

Zostavax and its administration are covered under the Part D pharmacy benefit for Medicare members, as required by CMS.

Claims for Zostavax and its administration must be processed through Caremark, MHP’s pharmacy benefit manager, to apply the associated costs appropriately (TrOOP and member co-payment).

MHP offers three options for obtaining Zostavax for our MedicareADVANTAGE members:

Submit a paper claim (CMS1500) for Zostavax and administration to MHP’s Pharmacy Department* for processing at Caremark under the member’s Part D benefit. Caremark will reimburse you at the same rate MHP reimburses a Part D network pharmacy, minus the member’s Part D co-payment. Caremark will send you a remittance advice that includes the co-payment amount collected from the member.

Write a prescription for Zostavax to be filled at a network pharmacy. The member may bring the vaccine or it can be shipped to your office for administration. The pharmacy will bill MHP for the vaccine under the member’s Part D benefit. Your office may submit a paper claim (CMS1500) to MHP* for the administration.

Write a prescription for Zostavax to be filled and administered at a network pharmacy (dependent upon state regulations). The pharmacy will bill MHP for the vaccine and administration under the member’s Part D benefit.

*For this claim only:
Mercy Health Plans
ATTN: Pharmacy Dept.
14528 S. Outer Forty Rd.
Chesterfield, MO 63017

Contact your provider relations representative for additional information.

Seasonal flu vaccine codes
90655	Influenza virus vaccine split preservative free 6-35 month
90656	Influenza vaccine no preservative age 3 years+
90657	Influenza vaccine age 6-35 months
90658	Influenza vaccine age 3 years+
90660	Influenza live attenuated vaccine given through nose
Administration codes
90465-90474	Influenza administration codes
G0008 and G0009	Pneumococcal vaccine administration codes
Influenza A (H1N1) vaccine codes
Medicare
G9142	Influenza A (H1N1) vaccine, any route of administration
G9141	Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family)
Non-Medicare
90663	Influenza virus vaccine, pandemic formulation
90470	H1N1 immunization administration (intramuscular, intranasal)
Pneumococcal vaccine codes
90669	Pneumococcal conjugate vaccine < 5 years
90732	Pneumococcal polysaccharide vaccine age 2 years+

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