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Coverage of Meningococcal ABCWY vaccine and Smallpox and Mpox Vaccine for Independence Commercial Members (Retroactively Effective to October 26, 2023)


Purpose

Retroactively effective to October 26, 2023, the purpose of this communication is to provide notice regarding the coverage criteria for meningococcal groups A, B, C, W, and Y vaccine (Penbraya) and smallpox and mpox vaccine, live, non-replicating (Jynneos) vaccine for Independence Commercial members.

Background

Meningococcal groups A, B, C, W, and Y vaccine (Penbraya) induces the production of bactericidal antibodies specific to the capsular polysaccharides of Neisseria meningitidis serogroups A, C, W, and Y and to outer membrane protein factor H binding protein subfamily A and B variants of N. meningitidis group B.


Smallpox and mpox vaccine, live, non-replicating (Jynneos) vaccine is a live vaccine produced from the strain Modified Vaccinia Ankara-Bavarian Nordic, an attenuated, non-replicating orthopoxvirus that creates a humoral and cellular immune response to orthopoxviruses.
 
FDA APPROVALS


On October 20, 2023, FDA approved meningococcal groups A, B, C, W, and Y vaccine (Penbraya) for active immunization to prevent invasive disease caused by Neisseria meningitidis serogroups A, B, C, W, and Y for individuals 10 through 25 years of age.


On September 24, 2019, s​mallpox and mpox vaccine, live, non-replicating (Jynneos) vaccine is FDA-approved for the prevention of smallpox and mpox disease in adults 18 years of age and older determined to be at high risk for smallpox and mpox infection.


ADVISORY COMMITTEE ON IMMUNIZATION PRACTICES (ACIP) RECOMMENDATIONS

On October 26, 2023, the Advisory Committee on Immunization Practices (ACIP) recommended meningococcal groups A, B, C, W, and Y vaccine (Penbraya) for individuals 16 through 23 years of age when indicated by shared clinical decision-making for Meningococcal B vaccination and for individuals 10 years of age and older at increased risk of meningococcal disease (e.g., due to persistent complement deficiencies, complement inhibitor use, or functional or anatomic asplenia) due for the MenACWY and MenB vaccine.


On October 26, 2023, the Advisory Committee on Immunization Practices (ACIP) recommended the two-dose Jynneos (smallpox and mpox vaccine, live, non-replicating) vaccine for individuals 18 years and older who are at risk for Mpox. ​


Coverage Statement

Meningococcal Vaccine
 
Meningococcal groups A, B, C, W, and Y vaccine (Penbraya) is considered medically necessary and, therefore, covered as a preventive service for the following individuals:

  • Individuals 16 through 23 years of age when indicated by shared clinical decision-making for meningococcal B vaccination.
  • Individuals 10 years of age and older at increased risk of meningococcal disease (e.g., due to persistent complement deficiencies, complement inhibitor use, or functional or anatomic asplenia) due for the MenACWY and MenB vaccine. 

Smallpox and Mpox Vaccine
 
Smallpox and mpox vaccine, live, non-replicating (Jynneos) vaccine is considered medically necessary and, therefore, covered as a preventive service as a two-dose vaccine for individuals 18 years and older who are at risk for Mpox.

According to ACIP, risk factors for Mpox are:

  • Gay, bisexual, and other men who have sex with men, transgender or nonbinary individuals who in the past six months had one of the following:
    • A new diagnosis of at least one sexually transmitted disease
    • More than one sex partner
    • Sex at a commercial sex venue
    • Sex in association with a large public event in a geographic area where mpox transmission is occurring.
  • Sexual partners of individuals with the aforementioned risk factors
  • Individuals who anticipate experiencing any of the aforementioned risk factors​

Coding

THE FOLLOWING CODE IS USED TO REPRESENT SMALLPOX AND MPOX VACCINE, LIVE, NON-REPLICATING (JYNNEOS)

90611

THE FOLLOWING CODE IS USED TO REPRESENT MENINGOCOCCAL GROUPS A, B, C, W, AND Y VACCINE (PENBRAYA) EFFECTIVE 01/01/2024​

​90623

THE FOLLOWING CODE IS USED TO REPRESENT MENINGOCOCCAL GROUPS A, B, C, W, AND Y VACCINE (PENBRAYA) PRIOR TO DATE OF SERVICE 01/01/2024​
90749


12/15/2023