Annual Vaccine Coverage Update

Covered Vaccines & Immunizations 

The vaccines and immunizations in this update apply to all groups that use OptumRx, as summarized in the ‘Seasonal Vaccine Coverage’ and ‘Non-seasonal Coverage’ sections, align with the recommended vaccines included on the ACA HCR list of preventive medications. This list undergoes periodic review and may change based on guideline updates.

Seasonal Vaccine Coverage 

Flu Vaccine Coverage

Members 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 refer to their plan materials. Please note that BlueCross BlueShield will not be conducting any flu vaccine clinics for groups.

Who Is Covered for Seasonal Flu Vaccines?

Flu vaccine coverage automatically applies to all applicable non-grandfathered Fully Insured, ASO, and Exchange membership. 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 (2024-2025)

The vaccines covered under the program this year, for both commercial and ACA members, are:

•    Afluria
•    Fluad*
•    Fluarix 
•    Flublok 
•    Flucelvax 
•    FluLaval 
•    FluMist Intranasal**
•    Fluzone High-Dose PF*
•    Fluzone 

* 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 Vaccine Coverage

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

All members whose groups must adhere to ACA regulations (non-grandfathered groups), commercial members with this benefit election, and all ACA members have coverage for the following vaccines. Similar to seasonal flu vaccines, grandfathered groups can choose non-seasonal vaccine coverage with either a $0 copay or associated plan copay.

*FDA expanded approval; Gardasil now available for use in individuals aged 9 through 45 years. 
^FDA approved in June 2024, Capvaxive is indicated for active immunization in adults aged ≥ 18. 
¥Abrysvo is the only RSV vaccine approved for use during pregnancy; dose should be received between 32 and 36 weeks. 
# As of July 2024, the age indication for Arexvy expanded to ≥ 50 years for individuals at increased risk of severe RSV outcomes.
Ϯ Mresvia is indicated for adults aged ≥ 60 to protect against RSV. 
≠Jynneos is for prevention in individuals aged ≥ 18 who are determined to be at high risk for smallpox or monkeypox infection. 

Updates to the Health Care Reform Immunization List

The following vaccines have been removed from the HCR immunization list, effective February 1, 2024:
•    Prevnar 13
•    Menactra
•    DT (Diphtheria and Tetanus)

These vaccines are no longer recommended as routine immunizations, according to the updates from the Advisory Committee on Immunization Practices (ACIP) for both adult and pediatric vaccination schedules. Instead, alternative pneumococcal, meningococcal, and diphtheria-tetanus vaccines, which offer more effective prevention and broader coverage, have been recommended and added to the HCR immunization list.