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H1N1 Vaccination Coverage

Oct 12, 2009


OCTOBER 8, 2009

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Important H1N1 Vaccination Coverage Information

The U.S. Food and Drug Administration has approved and obtained a vaccine to combat the H1N1 virus (also know as the "Swine Flu"), and it's expected to be available later this month. The following provides you with details on expanded benefits coverage for the vaccine and related medications, as well as important information pertaining to self-insured, Administrative-Services Only (ASO) clients.

Coverage Details

The following changes to pharmacy benefit coverage related to the H1N1 virus have been enacted:

  • Waived member deductibles, coinsurance, and co-pays. First-dollar coverage for the administration of the H1N1 vaccine by contracted providers to fully-insured members, regardless of current vaccination benefit. Providers are expected to accept insurance payment in full so that no out-of-pocket costs will be incurred by members.
  • Expanded H1N1 coverage benefit for ASO clients. All ASO claims will adhere to the first-dollar coverage benefit by default, and any client opt-out will be treated as an exception. ASO clients will have the opportunity to opt-out of first-dollar coverage; sales representatives will need to distribute a H1N1 Vaccination Coverage Opt-Out Form to ASO clients, and clients will have 30 days to return the form to opt-out of providing expanded coverage to members. The H1N1 Vaccination Coverage Opt-Out Form will be distributed to impacted clients over the next several weeks.

    Anthem Blue Cross recommends that ASO clients strongly consider the financial implications of opting out of the expanded vaccination coverage benefit for their members. The H1N1 administration fee is typically $15 or less. Vaccination is the best protection against contracting the H1N1 flu, which can lead to absenteeism and increased health care utilization, including costly hospitalizations. The U.S. health care system has a responsibility to achieve maximum vaccination coverage and effective treatment of H1N1 flu risks. In light of these considerations, Anthem is eager to do their part to ensure that their members are immunized against this virus.
  • Vaccine availability. The U.S. government has purchased 200 million doses of H1N1 vaccine and will make the vaccine available this month, both as a nasal spray route of administration and traditional needle vaccination. The U.S. Department of Health and Human Services (HHS) will be distributing the vaccine to state health departments, and it is anticipated that a significant proportion of the H1N1 vaccine will be administered through non-traditional providers such as pharmacies, retail clinics, schools, universities, and public health clinics. Anthem's network management team is working closely with NextRx to complete contracting agreements with retail pharmacies and immunization vendors to increase access to the H1N1 vaccine. The H1N1 vaccine is expected to be released in mid-October.
  • Minimizing member cost for treatment. For members who require the antiviral medications Relenza and Tamiflu for the treatment of the H1N1 virus, benefit coverage will be increased. These medications will be covered as Tier 2 formulary for all members with pharmacy benefits. 

Future Communications

Employers will be notified of benefit changes related to H1N1 in the fall issue of the MyAnthem News employer newsletter, which will be distributed to small and large employer groups on Friday. Members will be able to visit the health plan web site for information on expanded vaccination benefits.

Additional details will be communicated as soon as they become available.

For More Information

For information on the expanded vaccination benefit and how our health plan is responding to H1N1, refer to the Frequently Asked Questions.

For more information on the H1N1 virus, including vaccine availability, You may also review What You Need To Know About H1N1 Flu Prevention for information about the H1N1 virus.

For questions related to benefit coverage levels and access, contact your sales representative.

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