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BCBSIL to Require Adherence to Vaccine Guidelines

Posted November 29, 2017

The Centers for Disease Control and Prevention (CDC) website refers to vaccines as one of the safest ways individuals can help protect their health. The CDC advises that patients talk with their doctors about what vaccines they may safely receive based on their individual health history or other conditions.1

To help keep Blue Cross and Blue Shield of Illinois (BCBSIL) 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).

BCBSIL has 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 human papillomavirus (HPV) prevention and one for the prevention of shingles resulting from the herpes zoster virus – BCBSIL 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 to be 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 9 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 9 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 helps prevent 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. BCBSIL considers the vaccine medically necessary for anyone age 50 or older in recognition of the FDA guidance.

Details on the approved immunization schedule can be found in the Standards and Requirements/Clinical Payment and Coding Policies section – select the Preventive Services link to view the applicable policy.

*This information does not apply to HMO member claims.

1CDC website (2016), Accessed Nov. 17, 2017, at https://www.cdc.gov/vaccines/adults/reasons-to-vaccinate.html.

Third party brand names are the property of their respective owners.

The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider.