News Flash

CareFirst's Policy Regarding H1N1 Vaccine

The following is the CareFirst BlueCross BlueShield policy regarding the administration of the H1N1 flu vaccine for all members except those in self-insured employer groups because those groups decide which benefits they will and will not offer to their plan participants.

Please note that this policy applies to benefits related to the H1N1 vaccine when administered in a doctors' office, retail clinic, pharmacy, hospitals or any other clinically appropriate setting. Patients age 10 and older require only one round of the vaccine; children less than 10 years will require 2 rounds of the vaccine.

What is New?

The annual flu vaccine, which is available each fall and winter, is normally administered by a contracted doctor and is administered in a doctor's office or other clinical setting within the CareFirst network. The H1N1 vaccine, on the other hand, will be administered in many non-network locations, such as local health departments, schools, pharmacies and workplaces. The CareFirst H1N1 policy allows us to process these types of H1N1 claims which would otherwise be rejected.

What This Means for You

• If your plan benefits currently include immunization benefits, CareFirst will cover the cost to administer the H1N1 vaccine per your group's benefit contract, but waive:
  1. Any contractual penalties for obtaining services from out-of-network providers, and
  2. Any referral or authorization requirements
     
  
  Relaxing these requirements for H1N1 will increase your options for receiving the vaccination.
• You will still be responsible for any cost sharing provisions (i.e., deductible, copay or coinsurance) as outlined in your contract.
• For the small number of insurance plans that do not offer immunization benefits, CareFirst will reimburse those members at 100% of the allowed benefit.
• Benefits are also provided for Tamiflu and Relenza, the drugs known to ease the symptoms of influenza, under the group's prescription drug plan. These drugs are tier 3 (non-preferred). Eligible members may receive ten pills within a six-month period, which is enough for the five-day course of treatment approved by the Food and Drug Administration to treat the influenza virus.

Below are answers to some of the most frequently asked questions regarding the H1N1 flu.

Will I have to pay anything for the H1N1 vaccine?

To make the vaccine accessible to as many members as possible, CareFirst has agreed to waive any contractual penalties for obtaining services from out-of-network providers, as well as waive any referral or authorization requirements. However, members will still be responsible for any cost sharing provisions (i.e., deductible, copay or coinsurance) as outlined in their contract. Please note: If a member receives the vaccine from a non-participating provider and the cost exceeds CareFirst's allowed amount, the member may be subject to balance billing since a non-participating provider does not have an agreement with CareFirst to accept our allowed amount as payment in full.

Will BlueChoice HMO members be required to obtain the vaccine from their PCP?

No, HMO members are permitted to receive the vaccine from any licensed distributor, regardless of whether they are in the BlueChoice provider network. Please note: If a member receives the vaccine from a non-participating provider and the cost exceeds CareFirst's allowed amount, the member may be subject to balance billing since a non-participating provider does not have an agreement with CareFirst to accept our allowed amount as payment in full.

Will I be required to pay any up-front "out-of-pocket" fees for this service?

It will depend entirely on the provider who administers the vaccine. It is likely that most members will be asked to pay for at least their co-pay/coinsurance at the time that the vaccine is administered. Please note: If a member receives the vaccine from a non-participating provider and the cost exceeds CareFirst's allowed amount, the member may be subject to balance billing since a non-participating provider does not have an agreement with CareFirst to accept our allowed amount as payment in full.

What happens if my plan has no out-of-network option (such as an EPO or lock-in HMO)?

These members will receive the same benefit that they receive when receiving care from an in-network provider. Please note: If a member receives the vaccine from a non-participating provider and the cost exceeds CareFirst's allowed amount, the member may be subject to balance billing since a non-participating provider does not have an agreement with CareFirst to accept our allowed amount as payment in full.

I received a vaccination at a local health fair and they asked only for a $10 "contribution"? Is this cost reimbursable?

A voluntary contribution is not reimbursable. If, however, you are required to pay a fee in order to receive the vaccine, then the allowed benefit is reimbursable under the terms of the group's benefit contract.

Where and when will the vaccine be available?

Every state is developing its own vaccine delivery plan. The vaccine will be available very soon in a combination of settings such as vaccination clinics organized by local health departments, healthcare provider offices, schools, and other private settings, such as pharmacies and workplaces.

For information on your specific jurisdiction, visit State/Jurisdiction Contact Information for Health Care Providers Interested in Providing H1N1 Vaccine.

How does H1N1 flu spread?

The CDC has identified several cases of H1N1 flu in the United States. According to the CDC, influenza is thought to spread mainly person-to-person through coughing or sneezing of infected people. If you get sick, the CDC recommends that you stay home from work or school and limit contact with others to keep from infecting them.

How can I protect myself from the H1N1 flu?

Spread of the H1N1 flu virus is thought to be happening in the same way that seasonal flu spreads. Flu viruses are spread mainly from person to person through coughing or sneezing of people with influenza. Sometimes people may become infected by touching something with flu viruses on it and then touching their mouth or nose. Therefore:

• Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue away after you use it.
• Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hand cleaners are also effective.
• Avoid touching your eyes, nose or mouth. Germs spread this way.
• Try to avoid close contact with sick people.

We encourage our members, groups and brokers to refer to the Centers for Disease Control (CDC) Web site for the most accurate, updated information and guidance.