Immunization shots for influenza are a covered benefit under OGB’s PPO, HMO, Medical Home HMO and CDHP-HSA health plans whether the shot is administered at a doctor’s office, health fair, hospital, medical clinic or pharmacy.

Claims for flu shots are processed by each OGB health plan subject to any applicable co-payment and deductible. If your plan has an annual deductible and you have not yet met that deductible, the claim is applied to the deductible and the plan pays any amount that exceeds the deductible. If your plan has no deductible but requires a co-payment, the plan will reimburse you for the amount that exceeds your co-payment.

If you receive your flu shot from a doctor’s office or medical clinic that is a participant in your health plan’s network, the medical facility will file a claim for you.

If you receive your flu shot at a pharmacy and your pharmacy agrees to file a claim directly with your health plan provider, no action is needed on your part.

However, if the doctor or pharmacy does not file a claim for you, you must file a claim to receive benefits. Here are the steps you need to take... Get your flu shot and pay for it. If you have an OGB general-purpose flexible spending arrangement (GPFSA) card, do not use it to pay for the vaccine. Be sure the receipt includes the date administered, the cost, the vaccine name, the name of the person who received the shot and the medical provider or pharmacist who administered it. Follow these instructions to file a claim... Click on the link below to your health plan’s claim form. Complete the form online and print it, or print the blank form and fill it in using blue or black ink. Sign and date the form. Mail the form and the original receipt (not a cash register receipt or a copy) to the address listed below (and on the form).

Health Plan	Covered Benefit	Link to Claim Form	Claim Form Mailing Address
PPO (Administered by Blue Cross & Blue Shield of Louisiana)	Covered at 90%; subject to deductible	Flu shots rendered at a pharmacy: Flu Vaccination Claim Form Flu shots rendered at health fairs, job sites, etc.: BCBSLA 1500 Claim Form	Blue Cross & Blue Shield of Louisiana P.O. Box 98029 Baton Rouge, LA 70898-9029
HMO (Administered by Blue Cross & Blue Shield of Louisiana)	Covered at 100% of allowable amount; no deductible	Flu shots rendered at a pharmacy: Flu Vaccination Claim Form Flu shots rendered at health fairs, job sites, etc.: BCBSLA 1500 Claim Form	Blue Cross & Blue Shield of Louisiana P.O. Box 98029 Baton Rouge, LA 70898-9029
Medical Home HMO (Fully insured by Vantage Health Plan)	Covered at 100% of allowable amount; no deductible	Flu Vaccination Claim Form (Medical Home HMO plan only)	Vantage Health Plan 130 DeSiard St., Suite 300 Monroe, LA 71201
CDHP-HSA (Administered by Blue Cross & Blue Shield of Louisiana)	Covered at 80%; subject to deductible	Flu shots rendered at a pharmacy: Flu Vaccination Claim Form Flu shots rendered at health fairs, job sites, etc.: BCBSLA 1500 Claim Form	Blue Cross & Blue Shield of Louisiana P.O. Box 98029 Baton Rouge, LA 70898-9029

If you have a general-purpose flexible spending arrangement (GPFSA), you can file for reimbursement of any remaining out-of-pocket costs from DataPath Administrative Services (the GPFSA administrator) after your claim has been processed by your health plan and you have received an explanation of benefits (EOB). Here’s what to do...

• Complete a GPFSA medical expense claim reimbursement form.
• Fax the completed form and a copy of your EOB to 1-888-472-6777 (toll-free) or mail your claim to DataPath Administrative Services, 1601 Westpark Dr., Suite 9, Little Rock, AR 72204.

Influenza Prevention & Treatment Information

LA Department of Health and Hospitals
Centers for Disease Control and Prevention
American Medical Association