Influenza Vaccine Reimbursement Form
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1Influenza Vaccine Reimbursement Form
Please use this form to obtain reimbursement if you received a flu shot or FluMist in a location other
than a doctor’s office. Please submit one form for each member.
Please print
Member identification number _____________________________________________________________
Member information
Last _________________________________________ First _____________________________ M.I. ______ Date of birth ____________
Address ____________________________________________________________________________________________________________
City ___________________________________________________________________ State _________ ZIP code ___________________
Type of service:
Flu shot
FluMist
Amount paid ___________________________________________________________
____________________________________________________
Location where you received the flu shot or FluMist
_____________________________________________________________
Date you received the flu shot or FluMist
Claims Department (internal use)
Procedure Code #
Description
90654
Influenza virus, split virus, preservative free, for intradermal use
90657
Influenza virus vaccine, split virus, for children 6 – 35 months of age, for intramuscular use
90658
Influenza virus vaccine, for use in individuals 3 years of age and above, for intramuscular use
90660
Influenza virus vaccine, live, for intranasal use
Diagnosis Code #
Description
V04.81
Prophylactic vaccination and inoculation influenza
Mail this form and receipt for reimbursement up to $25 to:
Keystone Health Plan East
BlueCard PPO
Keystone 65 HMO
Personal Choice
®
P.O. Box 69353
Personal Choice 65
PPO
SM
Harrisburg, PA 17106-9353
P.O. Box 69352
Harrisburg, PA 17106-9352
Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield —
independent licensees of the Blue Cross and Blue Shield Association.
2011-0280 (06/11)
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