Commonwealth of Massachusetts Executive Office of Health and Human Services Division of Medical Assistance 600 Washington Street Boston, MA 02111 MassHealth Prescriber Bulletin 3 April 2000 TO: Physicians, Outpatient Hospitals, and Nurse Practitioners Participating in MassHealth FROM: Mark E. Reynolds, Acting Commissioner RE: Pneumococcal Conjugate Vaccine Background The Food and Drug Administration (FDA) recently approved the use of Prevenar, a pneumococcal conjugate vaccine manufactured by Wyeth-Lederle. The Advisory Committee on Immunization Practices (ACIP) has issued draft recommendations identifying the groups of people who should receive the pneumococcal conjugate vaccine. Guidelines for Vaccine Administration The ACIP has recommended the pneumococcal conjugate vaccine for use in all infants from six weeks to 23 months of age, and in children 24 months of age through 59 months of age who are in defined risk groups that include those with immunocompromising conditions or selected chronic diseases, and children with sickle cell disease, functional or anatomic asplenia, and HIV. The vaccine is also recommended for all children in this age group who are African American, American Indian, or Alaska natives. The ACIP recommends that the vaccine be given according to the following schedule: •If begun between six weeks and six months of age, a three-dose primary series two months apart, with a booster between 12 and 15 months. •If begun between seven and 11 months of age, a two-dose primary series two months apart, with a booster two months after completion of the primary series. •If begun between 12 and 23 months of age, a two-dose primary series two months apart, with no booster. •If begun between 24 and 59 months of age, and the child is healthy, one shot is recommended. •If begun between 24 and 59 months of age, and the child is defined with an underlying medical condition, a two-dose primary series two months apart, with no booster. MassHealth Prescriber Bulletin 3 April 2000 Page 2 Reimbursement The Division will cover Prevenar when administered to eligible MassHealth members according to the recommendations for vaccine administration identified above, for dates of service on or after February 24, 2000, except in instances where the vaccine is available free of charge through the Department of Public Health (DPH). Until the Division has a service code specific to the pneumococcal conjugate vaccine, providers must use Service Code 90749 (unlisted immunization procedure) to bill for the vaccination. Reimbursement will be on an individual- consideration basis (see 130 CMR 433.406). MassHealth Providers and TAFDC Immunization Certification To be eligible for Transitional Aid to Families with Dependent Children (TAFDC), applicants and recipients of TAFDC, unless they are exempt for medical or religious reasons, must verify that their children have been properly immunized. If you are the recipient's health-care provider, you are expected to certify the immunization status of any preschool child under your care. However, it is the member's responsibility to ask you to certify the child's immunization status and to provide you with the appropriate form. The form is very brief. It requires you to check off a section indicating the child's immunization status, including the date of any scheduled appointment to bring the child up-to-date on age-appropriate immunizations. The form must be signed by the appropriate medical staff. When an immunization is the primary purpose of an office or other outpatient visit, the provider may bill the Division only for the administration of the vaccine. However, when the immunization is not the primary purpose of the office or other outpatient visit, the provider may only bill for the visit, and not for the administration of the vaccine. The provider cannot bill the member, nor will the Division reimburse the provider, for completing the immunization certification form. Questions If you have questions about the pneumococcal conjugate vaccine or the recommendations for its administration, call the Massachusetts Immunization Program at (617) 983-6800. For questions about billing for the vaccine, call the Unisys Provider Services Department at (617) 628-4141 or 1-800-325-5231. If you have questions about TAFDC Immunization Certification, call the worker whose name and phone number are listed on the form.