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Benefits 101: Adults Need Vaccines, Too

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If you’re concerned about the flu or shingles, you might consider getting one of the vaccines that can prevent these illnesses.  Your insurance coverage for these shots varies depending on your plan and the circumstances.


There are a few differences in coverage, depending on which insurance plan you have chosen. Here’s a helpful guide.

The Flu Vaccine

As noted elsewhere, this year’s flu season is shaping up to be one of the worst in recent years. The Centers for Disease Control (CDC) recommends that everyone who can tolerate the shot should be inoculated.

The flu immunization is part of the Capital BlueCross Schedule of Preventive Care Services, and is covered through the Lehigh University Comprehensive, PPO, and KeystoneHMO medical benefit plans.

In order to receive in-network coverage for this service, members need to obtain the vaccine from an in-network medical provider, including an outpatient hospital provider, doctor’s office, or retail health center. (Retail health centers can be located by calling customer service, or searching for them at the Capital Blue Cross web site.)


Families covered under the Comprehensive or PPO plans can also receive the flu vaccine at a pharmacy. Be aware, though, that pharmacies are considered out-of-network providers for flu shots. If you choose to use a pharmacy for your flu shots, you will need to pay at the time of service and submit a claim for reimbursement consideration. Coverage for flu shots received at a pharmacy is subject to out-of-network benefits, if available.

Flu shot coverage also varies depending on the recipient’s age (Pediatric: age 6 months through 20 years; Adult :age 21 and over), and the provider of service.  


  • Comprehensive Plan:  Pediatric flu shots waive deductible, and pay at 80% of the allowed amount with a participating or non-participating provider.  The Comprehensive plan limits benefits for Adult Preventive Services, and does not cover preventive flu shots for adult members.  
  • PPO 80 Plan:  Pediatric flu shots waive deductible, and pay at 80% of the allowed amount with an in-network medical provider, or 70% of the allowed amount with an out-of-network provider. Adult preventive flu shots are also covered, subject to deductible, but only with an in-network medical provider.
  • PPO 100 Plan:  Pediatric flu shots waive deductible, and pay at 100% of the allowed amount with an in-network medical provider, or 80% of the allowed amount with an out-of-network provider. Adult preventive flu shots are also covered at 100% of the allowed amount, but only with an in-network medical provider.
  • Keystone HMO Plan:  Pediatric and adult preventive flu shots are covered at 100% of the allowed amount when administered by the PCP, or with a valid referral to another HMO network medical provider. Flu shots received from an out-of-network provider are not covered.

The Shingles Vaccine

Most people age 50 and older had chickenpox as a child. The same virus that causes chickenpox causes shingles. The virus stays in your body and can resurface at any time as shingles. People who have had shingles report that it is extremely painful and debilitating.

Zostavax is a live virus vaccine used for the prevention of shingles. If you are age 50 or older, you might consider the shingles vaccine.

This immunization is part of the Capital BlueCross Schedule of Preventive Care Services, and is covered through the Lehigh University PPO and HMO medical benefit plans.   We recommend you make every effort to get the vaccine at a network medical provider to reduce upfront costs. 

If you would like to get the vaccine, your first step should be to call your doctor (for Keystone members, your PCP) to discuss getting the vaccination at his or her office.

Because it is a live vaccine and requires refrigeration, many doctors don’t stock Zostavax. Your doctor will need to order the shot and have it delivered.


Getting Zostavax At The Pharmacy

Some doctors choose not to stock or administer the vaccination. In this case, your doctor can refer you to another provider who performs this service. If you aren’t able to make suitable arrangements with a medical provider, your doctor can write a script for you to get the vaccine at a pharmacy.

The doctor may instruct you to get the vaccine administered at the pharmacy, or to obtain the vaccine, and bring it back to his or her office for administration. In either case, you will need to pay for the cost of the service and then submit an itemized bill to your medical plan.

Coverage is as follows:


  • PPO 80 Plan:  Zostavax is covered, subject to member deductible and coinsurance.
  • PPO 100 Plan:  Zostavax is covered at 100% of the allowed amount with a network provider.
  • Keystone Plan:  Zostavax is coverage at 100% of the allowed amount with a network provider.   A referral is required if your provider obtains the vaccine from ACRO, or refers you to another network medical provider.  

The cost of the Zostavax shot is generally more than $200, so be sure to follow the proper procedure and get your reimbursement.

For More Information

If you have any questions about your coverage, or need a claim form to submit for your Zostavax dose, call Capital BlueCross Customer Service at 1-800-216-9741, or visit the Member page on the Captal BlueCross website.

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Spotlight is published monthly by Human Resources. Please address any comments to Hillary Kwiatek, Spotlight Editor, Human Resources, 428 Brodhead Avenue, send email to hik210@lehigh.edu, or call extension 85165.

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