Blue Review
A newsletter for physician, professional, facility, ancillary and Medicaid providers

November 2017

BCBSTX Requires Adherence to Vaccine Guidelines

Timely vaccines protect the health of children and adults, saving lives and ensuring the safest, most effective disease prevention possible. To help keep Blue Cross and Blue Shield of Texas (BCBSTX) members safe, doctors treating them should adhere to guidelines recommended by the U.S. Food and Drug Administration (FDA) and Advisory Committee on Immunization Practices (ACIP).

Two categories of vaccines may have been administered in a manner that doesn’t align with FDA and ACIP guidelines:

  • Human Papillomavirus (HPV) prevention
  • Prevention of shingles resulting from the herpes zoster virus

If these vaccines are given to BCBSTX patients, we will:

  • Continue reimbursing claims that are medically necessary, and supported by the FDA and ACIP guidelines
  • Consider vaccines administered outside of the FDA and ACIP recommendations as experimental, investigational or unproven, and will periodically review such claims for reimbursement
  • Recover reimbursements for these vaccines administered outside of the FDA and ACIP recommendations per our contracts

HPV Vaccination Guidelines
Gardasil®, Gardasil 9 and Cervarix are vaccines for the prevention of HPV infections and associated diseases, including cancers. Administration of these vaccines is recommended for males and females between 9 and 26 years old. Vaccination at ages 11 or 12 is optimal. Since 2006, these vaccines have been administered in three doses, with the second dose at one or two months after the first, and the third dose six months after the first. In October 2016, for patients between 9 and 14 years old, the ACIP recommendation was updated to two doses, with the second dose at six to 12 months after the first. For patients between 15 and 26 years old, the three-dose regimen is still recommended.

Shingles Vaccination Guidelines
Zostavax is a vaccine that prevents shingles and its complications. Zostavax is recommended as a single dose by the FDA at age 50 or older, and by the ACIP at age 60 or older. BCBSTX considers the vaccine medically necessary for anyone age 50 or older in recognition of the FDA guidance.

Immunization Schedule
Review the Preventative Services Policy CPCP006 for details on our complete, approved immunization schedule. The schedule can be found on the Clinical Payment and Coding Policies page under the Standards & Requirements tab on the BCBSTX provider website.