BCBSMT to Require Adherence to Vaccine Guidelines

Oct. 13, 2017

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 Montana (BCBSMT) 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).

We have identified two categories of vaccines that may have been administered in a manner that doesn’t align with FDA and ACIP guidelines.

For those vaccine categories – one for HPV prevention and one for the prevention of shingles resulting from the herpes zoster virus – BCBSMT will:

  • Continue to reimburse for claims that are medically necessary and supported by the FDA guidelines
  • Consider vaccines administered outside of the FDA and ACIP recommendations experimental, investigational or unproven, and will periodically review such claims
  • 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 nine and 26 years old. Vaccination at age 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 nine and 14 years old, the ACIP recommendation was updated to two doses, with the second dose 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.

BCBSMT considers the vaccine medically necessary for anyone age 50 or older in recognition of the FDA guidance.

Details on our complete, approved immunization schedule can be found on the BCBSMT Provider page under Standards & Requirements, Clinical Payment and Coding Policies, “Preventative Services Policy CPCP006”.