OGB's Medical Home HMO health plan (administered by Vantage Health Plan) covers influenza vaccinations administered at a pharmacy or by a primary care physician ("PCP"). The charge is paid at 100 percent of the Vantage Allowable when the vaccination is administered by an in-network provider or pharmacy.  Please check your pharmacy and provider directories for a listing of in-network pharmacies and providers.

You are only required to submit a flu vaccination claim form if the vaccination is administered by an out-of-network provider or if payment is required at the time of service.

Here are the steps you need to take when receiving your flu vaccination from an out-of-network provider:

1. Get your flu shot and pay for it. Do not use your OGB general-purpose flexible spending arrangement (GPFSA) card 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 pharmacist or PCP who administered it.
2. Here's how to file a claim
   • Complete a flu vaccination claim form. Click here for Medical Home HMO plan claim form.
   • Submit an original receipt (not a cash register receipt or a copy) with the claim form.
   • Sign and date the form. Mail the form and the original receipt to the address listed on the form.

If you have a general-purpose flexible benefits arrangement (GPFSA), you can file for reimbursement from DataPath Administrative Services (the GPFSA administrator) for any remaining out-of-pocket costs after your claim has been processed and you have received a check from Vantage Health Plan. Here's what to do:

• Request an Explanation of Benefits ("EOB") from Vantage.
• Complete a request for reimbursement claim form, available on DataPath's website.
• 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