Covered and Noncovered Services : Covered Services and Requirements

Vaccines for Children Program

The federal VFC Program was created to provide vaccines to eligible children through enrolled public and private providers. The VFC Program is part of a national approach to improving immunization services and levels.

Any child 18 years of age or younger who meets at least one of the following criteria is eligible for the VFC Program:

• Eligible for BadgerCare Plus or Medicaid.
• American Indian or Alaska Native, as defined by the Indian Health Care Improvement Act.
• Uninsured.
• Underinsured. (These children have health insurance but the benefit plan does not cover immunizations. Children in this category may only receive immunizations from a FQHC or an RHC; they cannot receive immunizations from a private health care provider using a VFC-supplied vaccine.)

When a vaccine becomes available through the VFC Program, the VFC Program notifies providers with clinical information about new vaccines, including the date they may begin ordering the vaccine. On the first of the month following that date, ForwardHealth will begin reimbursing only the administration fee for that vaccine.

Benefits of the Vaccines for Children Program

The VFC Program provides the following benefits:

• Vaccines are provided at no charge to public and private providers to immunize all eligible children.
• Eliminates or reduces vaccine costs as a barrier to the vaccination of eligible children.
• Vaccines recommended by the ACIP are automatically covered after approval by the CDC.

Reimbursement for Vaccines Provided to Children

If a vaccine is available through the VFC Program, providers are required to use vaccines from the VFC supply for members 18 years of age or younger. ForwardHealth reimburses only the administration fee for vaccines supplied by the VFC Program.

For vaccines that are not supplied by the VFC Program, providers may use a vaccine from a private stock. In these cases, ForwardHealth reimburses for the vaccine and the administration fee.

Beyfortus (nirsevimab), a monoclonal antibody, is used for the prevention of lower respiratory tract disease caused by RSV in infants or children. Although not a vaccine, the CDC's ACIP voted to include Beyfortus in the VFC Program. Providers are required to obtain Beyfortus for children from the VFC supply. ForwardHealth only reimburses an administration code for Beyfortus supplied through the VFC Program.