2023 to 2024 flu and pneumonia vaccines — reimbursements

Influenza and pneumonia vaccines are covered expanded benefits for Clear Health Alliance (CHA) members. Members have been advised to consult with their PCP for vaccine administration. Influenza and pneumonia vaccinations are also covered through our network pharmacies. Members should check with their pharmacist concerning the availability and administration of both vaccines.

For members from birth to 18 years old

Participating providers receive vaccines free for these Statewide Medicaid Managed Care Managed Medical Assistance (SMMC MMA) members through the federal Vaccines for Children (VFC) program.

Administration fee & modifiers:

• CHA will reimburse professional providers, primary care providers (PCP), or specialists (SPC) a $10 administration fee for the vaccine when billing the administration codes and the applicable CPT® code from the below Fee Schedule. Advanced practice registered nurse (APRN) /physician assistant (PA) administration fee reimbursement is $8 per unit.
• Modifier HA must be billed with CPT^® code for members aged 19 to 20.

Member age	Vaccine reimbursement/payment	Administration fee
Birth to 18	Reimbursed through VFC	$10 PCP/SPC; $8 APRN/PA
19 to 20	Paid according to Immunization fee schedule	$10 PCP/SPC; $8 APRN/PA
21+	Paid according to Immunization fee schedule	$10 PCP/SPC; $8 APRN/PA

Immunization fee schedules

Influenza vaccines
Code	Description	Max fee
90656	Influenza vaccine for administration into muscle, 0.5ml dosage, preservative free	$19.76
90658	Influenza vaccine for administration into muscle, 0.5ml dosage	$18.44
90672	Influenza vaccine quadrivalent, nasal administration	$23.75
90674	Influenza vaccine derived from cell cultures (ccIIV4) preservative/antibiotic free 0.5ml intramuscular	$30.10
90682	Influenza vaccine derived from DNA for injection into muscle, quadrivalent, preservative and antibiotic free	$60.73
90686	Influenza vaccine, intramuscular administration, 0.5ml dosage, quadrivalent, preservation free	$19.73
90688	Influenza vaccine intramuscular administration, 0.5ml dosage, quadrivalent MDV	$18.44
90756	Influenza vaccine derived from cell cultures, intramuscular, quadrivalent, antibiotic free, 0.5ml	$28.52

Pneumonia vaccines
Code	Description	Max fee
90671	Pneumococcal conjugate Vaccine 15 valent, intramuscular (PCV15)	$216.09
90677	Pneumococcal conjugate Vaccine 20 valent, intramuscular (PCV20)	$253.96
90732	Pneumococcal polysaccharide 23 valent subcutaneous or intramuscular	$117.08

Thank you in advance for promoting the importance of flu prevention in your practice and to our members during their visit. Together, we can help minimize the flu’s impact on patients, their families, and the community this flu season.