The following information and frequently asked questions are courtesy of the TRICARE Management Activity and Health Net Federal Services.
The 2010-2011 seasonal influenza vaccine contains three strains of influenza virus, one of which is the H1N1 strain that caused a worldwide pandemic last year.
Here are some helpful links to keep updated about TRICARE and military vaccination coverage:
General Flu Shot Information - Questions and Answers
Q: Will TRICARE cover my flu shot?
A: TRICARE covers flu vaccines based on the current flu season guidelines published by The Centers for Disease Control and Prevention (CDC) www.cdc.gov/flu/. According to the CDC, all persons, including school-aged children, who want to reduce the risk of becoming ill with influenza or of transmitting influenza to others should be vaccinated.
It is strongly recommended that the following people be vaccinated each year:
- Children ages 6 months through 18 years, with continued focus on those at high risk for flu complications (ages 6 months through 4 years)
- Adults age 50 years and older
- All women who are pregnant during the influenza (flu) season
- Health care workers involved in direct patient care
- Household contacts and caregivers of children less than 5 years of age and adults age 50 years and older, with particular emphasis on vaccinating contacts of children younger than 6 months.
- Household contacts of persons at high-risk for severe complications from influenza (flu)
- People who live in nursing homes and other long term care facilities
- Adults and children who have chronic pulmonary (including asthma), cardiovascular (except hypertension), metabolic and renal disorders (including diabetes, mellitus)
- Adults and children who have weakened immune systems, including those caused by medications or by HIV
- Adults and children who have any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders) that can compromise respiratory function or the handling of respiratory secretions or that can increase the risk for aspiration
- Children and adolescents aged 6 months to 18 years who are receiving long-term aspirin therapy and who therefore are experiencing Reye syndrome after influenza virus infection
TRICARE covers the following two types of vaccines:
- Flu shot - an inactivated vaccine containing a killed virus and given with a needle. This form of the vaccine may be used in all age groups.
- Nasal-spray flu vaccine (FluMist) - a vaccine made with live, weakened flu viruses that do not cause the flu. This form of the vaccination is limited only to healthy people who are not pregnant aged 2 to 49 years.
Q: Where do I go to get a flu shot?
A: TRICARE Prime, TRICARE Prime Remote (TPR) and TRICARE Prime Remote for Active Duty Family Members (TPRADFM) beneficiaries can obtain the flu vaccine from their Primary Care Manager (PCM) or any other TRICARE network provider without a referral. TRICARE Standard or TRICARE Reserve Select beneficiaries can obtain the flu vaccine from any TRICARE authorized provider. Be sure to talk with your doctor first about whether or not you should get a flu vaccine. To get a flu vaccine:
- Check with your local Military Treatment Facility (MTF) to find out if and when they are offering flu vaccines.
- Contact your PCM about your need for the flu vaccine and whether or not it is available at his or her office.
TRICARE beneficiaries can now receive the seasonal flu, H1N1 flu and pneumonia vaccines from a TRICARE retail network pharmacy at no cost.
For TRICARE For Life (TFL) beneficiaries, Medicare covers flu vaccinations and TRICARE would pay as second payer if needed.
Q: Are there any other TRICARE authorized flu shot providers?
A: If for some reason your PCM does not have flu vaccines available, you may want to consider obtaining your flu shot(s) at a network Convenient Care Clinic (CCC) or Urgent Care Clinic who is TRICARE-authorized.
CCCs are civilian health care facilities capable of treating minor illnesses and may offer preventive services as well, such as flu shots. They are usually located in high-traffic, retail-based locations that can include some retail pharmacies (e.g, CVS, Walgreens). Even though they are in retail pharmacy locations, these CCCs are not considered to be part of the pharmacy and are TRICARE authorized to provide flu shots. For example, to receive your flu vaccine from a Minute Clinic within a CVS pharmacy, you would be seen privately and individually by a Minute Clinic Nurse Practitioner. The CCC signage is very clear - so be sure you are using a CCC and not a separate flu shot provider.
CCCs are typically open seven days a week and appointments are usually not necessary because you are generally seen on a walk-in basis. Flu vaccines are considered a “preventive service” benefit and as such, copayments do not apply for TRICARE Prime TPR, TPRADFM, TRICARE Standard or TRS beneficiaries.
You can locate CCCs and Urgent Care Clinics through Health Net’s online provider directory or use the following links to locate a clinic near you:
Q: A TRICARE Prime and TRICARE Prime Remote for Active Duty Family Members (TPRADFM) beneficiary must obtain his/her SeasonaI Flu Shot from his/her PCM or a network provider. Is this true for the H1N1 vaccine, as well?
A: No. The requirement for a TRICARE Prime or TPRADFM beneficiary to obtain a referral from his/her PCM to receive the H1N1 vaccine only from a non-network, TRICARE-authorized provider has been temporarily waived from October 1, 2009 to May 1, 2010.
During this period, a TRICARE Prime and TPRADFM beneficiary may obtain the H1N1vaccine from a non-network, TRICARE-authorized provider without a PCM referral. However, the waiver is for administering the H1N1 vaccine only. If the non-network provider wants to have an office visit or provide another service for the beneficiary before administering the H1N1 vaccine, then Point-of-Service rules and higher beneficiary cost-shares will apply to those services.
Providers Only: Q: How should providers bill for H1N1 vaccine administration?
A: Since the United States government is providing the H1N1 vaccine free of charge, TRICARE providers may only bill TRICARE for the administration of the H1N1 vaccine.
For Outpatient Prospective Payment System (OPPS) claims providers should use the following:
- G9141 - Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family)
For Non-OPPS claims providers should use the following:
- 90470 - H1N1 immunization administration (intramuscular, intranasal), including counseling when performed.
Q: I am a TRICARE For Life (TFL) beneficiary. Will TFL and Medicare pay for my flu shot every year?
A: Medicare will pay for a flu shot once every flu season. In some cases this may mean twice in one year. For example, if you received a shot in January for one flu season, you could be inoculated again in October for the current flu season. The cost of the flu shot would be billed along with the doctor's visit. You cannot receive a flu shot from anywhere (e.g. a supermarket or pharmacy) and simply submit a claim to Medicare and TRICARE for reimbursement. It is important for you to find out in advance whether or not the entity providing the flu shots has made arrangements to submit claims for Medicare reimbursement. Medicare and TRICARE will only consider claims for services provided by a Medicare provider.
Q: When should I get a flu vaccination?
A: Beginning each September, the flu shot should be offered to people at high risk when they are seen by health-care providers for routine care or as a result of hospitalization. See the ACIP Recommendations for Using Inactivated Influenza Vaccine. The best time to get vaccinated is from October through November.
If you are sick with a fever when you go to get your flu shot, you should talk to your doctor or nurse about getting your shot at a later date. However, you can get a flu shot at the same time you have a respiratory illness without fever or if you have another mild illness.