Annual Vaccine Coverage Update

Seasonal Preventive Flu Vaccines

Members with PAI pharmacy benefit coverage with OptumRx can get flu vaccines covered under their pharmacy benefit at any in-network pharmacy. Flu vaccines administered by network pharmacies are subject to an administration fee that will be the group’s responsibility. Members are responsible for the full cost of the vaccine administered in out-of-network pharmacies.

For information on flu vaccine coverage available through their medical benefit, members can consult their plan documents.

Who Is Covered for Seasonal Flu Vaccines?

Flu vaccine coverage automatically applies to all applicable Non-Grandfathered plans. 

The vaccines that are on the ACA HCR vaccine list are equivalent to the vaccines on the combined Seasonal and Non-seasonal vaccine network lists below.

Cost

Members of Non-grandfathered groups have flu vaccine coverage for a $0 member copay. Grandfathered groups can elect seasonal vaccine coverage at either a $0 or associated plan copay.

Covered Flu Vaccines

The vaccines covered under the program this year are:

• Afluria Quadrivalent
• Fluad Quadrivalent*
• Fluarix Quadrivalent
• Flublok Quadrivalent
• Flucelvax Quadrivalent 
• Flulaval Quadrivalent
• Flumist Quadrivalent Intranasal**
• Fluzone High-Dose PF*
• Fluzone Quadrivalent

* Only approved for those aged 65 years and older.
** Only approved for those aged 2-49 years.

Covered Flu Treatments

For members diagnosed by a medical professional with acute uncomplicated influenza (A or B) infection, we offer coverage of the following treatments.

• oseltamivir (Tamiflu)

• Xofluza – For treatment of patients 5 years of age or older

  COVID-19 Vaccines

  COVID-19 vaccines, as approved by the FDA, are covered at no cost to the member under the ACA HCR $0 covered drug program.

  Non-seasonal Vaccine Coverage

  The following vaccines are covered for all members whose groups must follow ACA regulations. As with seasonal flu vaccines, Grandfathered groups can elect non-seasonal vaccine coverage at either a $0 or plan copay.

  VACCINE	MIN AGE	MAX AGE
  HAEMOPHILUS B	---	6 years
  HEPATITIS A (INACTIVATED)-HEPATITIS B (RECOMBINANT) VACCINE	---	---
  HEPATITIS A VACCINE	---	---
  HEPATITIS B VACCINE	---	---
  HEPATITIS B VACCINE RECOMB ADJUVANTED PREF SYR 20 MCG/0.5ML	18 years	---
  HUMAN PAPILLOMAVIRUS (HPV)	9 years	26 years
  MENINGOCOCCAL	---	---
  PNEUMOCOCCAL	---	---
  POLIOVIRUS VACCINE, IPV	---	17 years
  RESPIRATORY SYNCYTIAL VIRUS VACCINE [RECOMBINANT] (Abrysvo 120 mcg/0.5 mL) *	---	---
  RESPIRATORY SYNCYTIAL VIRUS VACCINE [RECOMBINANT (ADJUVANTED)] (Arexvy 120 mcg/0.5 mL) *	---	---
  ROTAVIRUS VACCINE, LIVE ORAL	---	8 months
  TOXOID COMBINATIONS	---	---
  VARICELLA VIRUS VACCINE LIVE	---	---
  VIRAL VACCINE COMBINATIONS	---	---
  ZOSTER VAC RECOMBINANT ADJUVANTED FOR IM INJ 50 MCG/0.5ML	19 years	---

   * Age restrictions will not be enforced as CDC/ACIP are pending decisions on additional populations to include
   

  Respiratory Syncytial Virus (RSV) Prevention 

  Beyfortus (nirsevimab) was approved by the FDA in July 2023. It is an immune globulin/monoclonal antibody IM injection for RSV prevention for children up to 24 months of age. It is covered as a non-seasonal vaccine per the stipulations above.