Clarification on Flu Shot Information for TRICARE Beneficiaries

Since an article regarding TRICARE coverage of influenza vaccinations was published on October 14, 2009, we have received requests for additional information.

Below is a chart comparing influenza vaccination coverage for TRICARE Prime, Standard, Extra and Prime Remote beneficiaries.

TRICARE Program	Influenza vaccination coverage	Vaccine location	Deductibles or cost-shares	Referral Required
Prime	Yes	Any network provider or military treatment facility (MTF)	None	No, except for Active duty Service members (ADSMs) seeking care from a non-network TRICARE-authorized provider must have a referral from their primary care manager (PCM).
Prime	Yes	Any non-network TRICARE-authorized provider	None	Yes, from their PCM
Prime Remote	Yes	Any network provider, MTF, PCM, or non-network TRICARE-authorized provider office, clinic or retail setting	None	No, including TPR ADSMs
Standard/Extra	Yes	Any network provider,  PCM, or non-network TRICARE-authorized provider office, clinic or retail setting	None	No

Here are some additional important points regarding influenza vaccination coverage:

• If a TRICARE Prime beneficiary goes to a retail outlet, such as a drug store or a grocery store for his or her vaccine and the vaccine is provided by a non-network TRICARE-authorized provider without a referral from the PCM, the shot will be paid under the point-of-service (POS) benefit. County health services employees are not TRICARE-authorized providers and therefore, the claim will not be paid.
• TRICARE currently does not recognize the administration of vaccines by pharmacists.
• Except for beneficiaries over 50 years old, flu mist is a TRICARE covered benefit when administered by a TRICARE Prime beneficiary’s PCM or other network provider.
• Beneficiaries should check with their PCM and local MTF for availability (hours, locations)

Influenza Vaccine Coding and Billing

The vaccine codes are as follows:

• 90655 – Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use
• 90656 – Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use
• 90657 – Influenza virus vaccine, split virus, when administered to children 6 -35 months of age, for intramuscular use
• 90658 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use
• 90660 – Influenza virus vaccine, live, for intranasal use
• 90661 – Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use
• 90662 – Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use
• 90662 – Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use
• 90663 – Influenza virus vaccine, pandemic formulation

The administration codes are as follows:

• 90465 – Immunization administration younger than 8 years of age (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) when the  physician counsels the patient/family; first injection (single or combination vaccine/toxoid), per day
• 90466 – Immunization administration younger than 8 years of age (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) when the physician counsels the patient/family; each additional injection (single or combination vaccine/toxoid), per day (List separately in addition to code for primary procedure)
• 90467 – Immunization administration younger than age 8 years (includes intranasal or oral routes of administration) when the physician counsels the patient/family; first administration (single or combination vaccine/toxoid), per day
• 90468 – Immunization administration younger than age 8 years (includes intranasal or oral routes of administration) when the physician counsels the patient/family; each additional administration (single or combination vaccine/toxoid), per day (List separately in addition to code for primary procedure)
• 90471 – Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid)
• 90472 – Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)
• 90473 – Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid)
• 90474 – Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)

Codes 90465-90474 must be reported in addition to the vaccine and toxoid code(s) 90655-90663.

For more information on flu season guidelines, visit the CDC Web site at www.cdc.gov/flu, www.tricare.mil, www.triwest.com/provider or contact TriWest at 1-888-TRIWEST (888-874-9378).

Published Date: 10/23/2009