Vaccines and vaccine administration

Vaccine codes and medical coverage by plan

  • Routine vaccines listed as NO (not covered) under Medicare may be covered under Medicare Part D pharmacy benefit.
  • All covered vaccines are considered preventive. Deductible, if applicable, will be waived for in-network providers. For self-funded plans, a dollar limit may apply to preventive services. Check individual plan benefits.
  • Age limits are based on FDA-approved indications. Exceptions to age limits are evaluated retrospectively by case. Example: Post bone marrow transplant, catch up.
  • VFC = Covered, BUT you must use the VFC program for members under 19 years of age
  • VFC only = Not covered for adult Medicaid/Healthy Michigan Plan members
  • BN = Brand-name drugs available (not an all-inclusive listing)
  • # = Coverage of these vaccines will be evaluated once FDA approval granted
Code Description HMO/EPO,
POS, PPO
Medicaid /Healthy Michigan Plan Medicare
Advantage plans
90476 Adenovirus vaccine, type 4, live, for oral use
BN: No product available
N/A N/A N/A
90477 Adenovirus vaccine, type 7, live, for oral use
BN: No product available
N/A N/A N/A
90581 Anthrax vaccine, for subcutaneous use
BN: BIOTHRAX
NO NO NO
90585 Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for percutaneous use
BN: BCG vaccine
YES NO NO
90586 Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, for intravesical use
BN: TICE BCG, THERACYS
YES NO NO
90620 Meningococcal recombinant protein and outer membrane vesicle vaccine, Serogroup B, 2 dose schedule, for intramuscular use
Ages: 10-25 years
BN: BEXSERO
YES YES (adults)
VFC (children)
NO
90621 Meningococcal recombinant lipoprotein vaccine, Serogroup B, 2 or 3 dose schedule, for intramuscular use
Ages: 10-25 years
BN: TRUMENBA
YES YES (adults)
VFC (children)
NO
90625 Cholera vaccine, live, adult dosage, 1 dose  NO NO NO
90630 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use
Ages: 18-64 years
BN: FLUZONE INTRADERMAL QUADRIVALENT
YES YES (adults) YES
90632 Hepatitis A vaccine (Hep A), adult dosage, for intramuscular use
Ages: 19 years & older
BN: HAVRIX, VAQTA
YES YES (adults)
VFC (children)
Covered under Medicare Part B only for the following diagnoses:
Z20.5, Contact with and (suspected) exposure to viral hepatitis; Z20.828, Contact with and (suspected) exposure to other viral communicable diseases
90633 Hepatitis A vaccine (Hep A), pediatric/adolescent dosage - 2 dose schedule, for intramuscular use
Ages: 0-18 years
BN: HAVRIX, VAQTA
YES VFC only Covered under Medicare Part B only for the following diagnoses:
Z20.5, Contact with and (suspected) exposure to viral hepatitis; Z20.828, Contact with and (suspected) exposure to other viral communicable diseases
90634 Hepatitis A vaccine (Hep A), pediatric/adolescent dosage-3 dose schedule, for intramuscular use
BN: No product available
N/A N/A N/A
90636 Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use
Ages: 18 years & older
BN: TWINRIX
YES YES (adults)
VFC (children)
NO
90644 Meningococcal conjugate vaccine, serogroups C & Y, and hemophilus influenza type b vaccine (Hib-MenCY), 4-dose schedule, when administered to children 6 weeks - 18 months of age, for intramuscular use
BN: No product available
N/A N/A N/A
Code Description HMO/EPO,
POS, PPO
Medicaid /Healthy Michigan Plan Medicare
Advantage plans
90647 Hemophilus influenza b vaccine (Hib), PRP-OMP conjugate (3 dose schedule), for intramuscular use
Ages: 6 weeks - 5 years
BN: PEDVAX HIB
YES VFC only NO
90648 Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for intramuscular use
Ages: 6 weeks - 5 years
BN: ACTHIB, HIBERIX
YES VFC only NO
906494 Human Papilloma virus vaccine, types 6, 11, 16, 18, quadrivalent (4vHPV4), 3 dose schedule, for intramuscular use
Ages: 9-26 only
BN: GARDISIL
YES NO NO
90650 Human Papillomavirus (HPV) vaccine, types 16 and 18, bivalent (2vHPV), 3 dose schedule, for intramuscular use
BN: No product available
N/A N/A N/A
906514 Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 3 dose schedule, for intramuscular use.
2 dose schedule for 11 and 12 year olds must be administered at least 146 days apart.
Ages 9-26
BN: GARDASIL 9
YES YES (adults)
VFC (children)
NO
90653 Influenza virus vaccine (IIV), inactivated, subunit, adjuvanted, for intramuscular use
Ages 65 years and older
BN: FLUAD
YES YES YES
90654 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, for intradermal use, ages 18-64 years only
BN: No product available
N/A N/A N/A
90655 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25 dosage for intramuscular use
BN: No product available
N/A N/A N/A
90656 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5ml dose, for intramuscular use
BN: AFLURIA PF2 ages 5 years & older
FLUVIRIN PF ages 4 years & older
YES YES (adults)
VFC (children)
YES
90657 Influenza virus vaccine, trivalent (IIV3), split virus, for intramuscular use
BN: No product available
N/A N/A N/A
90658 Influenza virus vaccine, trivalent (IIV3), split virus, 0.5ml dose, for intramuscular use
BN: FLUVIRIN ages 4 years 7 older
AFLURIA2 ages 5 years & older
YES YES (adults)
VFC (children)
NO
(see Q codes)
90660 Influenza virus vaccine, trivalent, live, for intranasal use
BN: No product available
N/A N/A N/A
90661 Influenza virus vaccine (ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, 0.5ml dose for intramuscular use
BN: No product available
N/A N/A N/A
90662 Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use
Ages: 65+ only
BN: FLUZONE HIGH DOSE
YES YES YES
90664 Influenza virus vaccine, live (LAIV) pandemic formulation, live, for intranasal use
BN: No product available
N/A N/A N/A
90666
#
Influenza virus vaccine (IIV), pandemic formulation, split virus, preservative free, for intramuscular use NO NO NO
90667
#
Influenza virus vaccine (IIV), pandemic formulation, split virus, adjuvanted, for intramuscular use NO NO NO
90668
#
Influenza virus vaccine (IIV), pandemic formulation, split virus, for intramuscular use NO NO NO
Code Description HMO/EPO,
POS, PPO
Medicaid /Healthy Michigan Plan Medicare
Advantage plans
Q2034 Agriflu influenza virus vaccine, split virus, for intramuscular use (AGRIFLU)
Ages: 18 years & older
BN: No active NDS for this code
N/A N/A N/A
Q20352 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (AFLURIA)
BN: AFLURIA
YES YES (adults)
VFC (children)
YES
Q2036 Flulaval influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (FLULAVAL)
BN: FLULAVAL No current NDC
YES YES (adults)
VFC (chilren)
YES
Q2037 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (FLUVIRIN)
BN: FLUVIRIN
YES YES (adults)
VFC (children)
YES
Q2038 Fluzone influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use
BN: No current NDC
YES YES (adults)
VFC (children)
YES
Q2039 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified)
BN: No current NDC
YES YES (adults)
VFC (children)
YES
90670 Pneumococcal conjugate vaccine, 13 valent, for intramuscular use
Ages: 0 years & older
BN: PREVNAR 13
YES YES (adults)
VFC (children)
YES
90672 Influenza virus vaccine, quadrivalent (LAIV4), live, for intranasal use
Ages: 2-49 years
BN: FLUMIST QUADRIVALENT
YES NO NO
906731 Influenza virus vaccine, trivalent (RIV3), derived from recombinant DNA (RIV3), hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use
Ages: 18 years & older
BN: Flublok
NO YES YES
90674 Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5mL dosage, for intramuscular use
Ages: 4 years & older
BN: FLUCELVAX QUADRIVALENT
YES YES (adults)
VFC (children)
YES
90675 Rabies vaccine, for intramuscular use
BN: IMOVAX, RABAVERT
YES YES Covered under Medicare Part B only for the following diagnoses:
A82.0, Sylvatic rabies; A82.1, Urban rabies; A82.9, Rabies, unspecified; Z20.3, Contact with and (suspected) exposure to rabies
90676 Rabies vaccine, for intradermal use
BN: No product available
N/A N/A N/A
90680 Rotavirus vaccine, pentavalent (RV5), 3 dose schedule, live, for oral use
Ages: 6 weeks-8 months only
BN: ROTATEQ
YES VFC only NO
90681 Rotavirus vaccine, human, attenuated (RV1), 2 dose schedule, live, for oral use
Ages: 6 weeks-6 months only
BN: ROTARIX
YES VFC only NO
906821 Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use
Ages: 18 and over
BN: FLUBLOK QUADRIVALENT  No current NDC<
NO YES YES
90685 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25ml dose for intramuscular use
Ages: 6 months & older
BN: FLUZONE QUADRIVALENT, EZ FLU
YES VFC only YES
90686 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5ml dose for intramuscular use
BN: FLUZONE QUADRIVALENT ages 6 months & older 
FLUARIX QUADRIVALENT ages 6 years & older 
FLULAVAL QUADRIVALENT ages 6 months & older 
AFLURIA2 QUADRIVALENT ages 5 years & older
YES YES (adults)
VFC (children)
YES
90687 Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25ml dose for intramuscular use
Ages: 6 months & older
BN: FLUZONE QUADRIVALENT
YES VFC only NO
90688 Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5ml dose for intramuscular use
Ages: 6 months & older
BN: FLUVALAL QUADRIVALENT, FLUZONE QUADRIVALENT
YES YES (adults)
VFC (children)4
YES
90689
#
Influenza virus vaccine quadrivalent (IIV4), inactivated, adjuvanted, preservative free, 0.25 mL dosage, for intramuscular use
BN: No product available
N/A N/A N/A
Code Description HMO/EPO,
POS, PPO
Medicaid /Healthy Michigan Plan Medicare
Advantage plans
90690 Typhoid vaccine, live, oral
BN: VIVOTIF CPDR
NO NO NO
90691 Typhoid vaccine, Vi capsular polysaccharide (ViCPs), for intramuscular use
BN: TYPHIM VI
NO NO NO
90696 Diphtheria, tetanus toxoids, acellular pertussis and poliovirus vaccine, inactivated (DTaP - IPV) when administered to children 4 through 6 years of age, for intramuscular use
BN: KINRIX, QUADRACEL
YES VFC only NO
90697
#

Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenza type b PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-HibHepB), for intramuscular use

BN: No product available

N/A N/A N/A
90698 Diphtheria, tetanus toxoids, acellular pertussis vaccine, Haemophilus influenza Type b, and inactivated poliovirus vaccine (DtaP-IPV/Hib), for intramuscular use
Ages: 6 weeks-4 years only
BN: PENTACEL
YES VFC only NO
90700 Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), for use in individuals younger than 7 years, for intramuscular use
Ages: 6 weeks to 6 years
BN: DAPTACEL, INFANRIX
YES VFC only NO
90702 Diphtheria and tetanus toxoids adsorbed (DT) for use in individuals younger than 7 years, for intramuscular use
Ages: 0-6 years
BN: Diptheria Tetanus Toxoid
YES VFC only NO
90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use
Ages: 6 months & older
BN: M-M-R-II
YES YES (adults)
VFC (children)
NO
90710 Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use
Ages: 1-12 years
BN: PROQUAD
YES VFC only NO
Code Description HMO/EPO,
POS, PPO
Medicaid /Healthy Michigan Plan Medicare
Advantage plans
90713 Poliovirus vaccine, inactivated, (IPV), for subcutaneous or intramuscular use
Ages: 6 weeks & older
BN: IPOL
YES YES (adults)
VFC (children)
NO
90714 Tetanus and diphtheria toxoids adsorbed (Td), preservative free, for use in individuals, for intramuscular use
Ages: 7 years & older
BN: Diptheria/Tetanus toxoids  TENIVAC
YES YES (adults)
VFC (children)
Covered by Medicare Part B only for the following ICD-10 diagnoses: Reference WPS LCD L34596
90715

Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), for use in individuals 7 years or older, for intramuscular use
BN: ADACEL ages 10 to 64 years
BOOSTRIX ages 10 years & older

YES YES
VFC
Covered by Medicare Part B only for the following ICD-10 diagnoses: Reference WPS LCD L34596
90716 Varicella virus vaccine (VAR), live, for subcutaneous use
Ages: 1 year & older
BN: VARIVAX
YES YES (adults)
VFC (children)
NO
90717 Yellow fever vaccine, live, for subcutaneous use
Ages: 0-99 years
BN: YF-VAX
NO NO NO
90723 Diphtheria, tetanus toxoids, acellular pertussis vaccine, hepatitis B, and inactivated poliovirus vaccine (DtaP-HepB-IPV), for intramuscular use
Ages: 6 weeks to 6 years
BN: PEDIARIX
YES VFC only NO
Code Description HMO/EPO,
POS, PPO
Medicaid /Healthy Michigan Plan Medicare
Advantage plans
90732 Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use
BN: PNEUMOVAX 23
YES YES (adults)
VFC (children)
YES
90733 Meningococcal polysaccharide vaccine serogroups A,C, Y, W-135, quadrivalent (MenACWY), for subcutaneous use
BN: No product available
N/A N/A N/A
90734

Meningococcal conjugate vaccine, serogroups A, C, Y and W-135, quadrivalent (MenACWY), for intramuscular use
BN: MENACTRA ages 9 months to 55 years
MENVEO ages 2 months to 55 years

YES VFC NO
907363 Zoster (shingles) vaccine, live (HZV), for subcutaneous injection
Ages: 60+ only
BN: ZOSTAVAX
YES YES NO
90738 Japanese encephalitis virus vaccine, inactivated, for intramuscular use
BN: IXIARO
NO NO NO
90739
Hepatitis B vaccine (HepB), adult dosage (2 dose schedule), for intramuscular use
Ages: 18 years & older
BN: HEPLISAV-B
YES NO YES
90740 Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use
Ages: 18 years & older
BN: RECOMBIVAX HB
YES YES (adults)
VFC (children)
YES
90743 Hepatitis B vaccine (HepB), adolescent (2 dose schedule), for intramuscular use
Ages: 11-15 years
BN: RECOMBIVAX HB
YES NO YES
907445 Hepatitis B vaccine (HepB), pediatric/adolescent dosage (3 dose schedule), for intramuscular use
Ages: 0-18 years
BN: ENGERIX B PEDIATRIC
YES YES (adults)
VFC (children)
YES
907465
Hepatitis B vaccine (HepB), 3 dose schedule, for intramuscular use
Ages: 16 years & older
BN: RECOMBIVAX HB, ENGERIX B
YES YES (adults)
VFC (children)
YES
90747 Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use
Ages: 18 years & older
BN: ENGERIX B
YES YES (adults)
VFC (children)
YES
90748 Hepatitis B and Hemophilus influenza b vaccine (Hib-HepB), for intramuscular use
Ages: 6 weeks - 15 months only
BN: No product available
N/A N/A N/A
90749 Unlisted vaccine/toxoid YES
Explanatory notes must accompany claim
YES
Explanatory notes must accompany claim
NO
90750 Zoster (shingles) vaccine (HZV), recombinant, sub-unit, adjuvanted, for intramuscular injection
Ages: 50 years & older
BN: SHINGRIX
YES YES NO
90756 Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5ml dose, for intramuscular use
Ages: 4 years & older
BN: FLUCELVAX QUADRIVALENT
YES YES (adults)
VFC (children)
YES

 

1 Flublok (90673) will not be covered for Priority Health commercial plan members for the 2018-2019 flu season due to the number of effective alternative products available at this time. It will continue to be evaluated by the health plan.

2 The CDC recommends special consideration when administering Afluria for ages 5 to less than 9 years.

3 At this time Zostavax (90736) is covered for members 60 and older only, absent a recommendation to reduce the age by ACIP. Coverage for Medicaid/Healthy Michigan Plan members is 50 years & older.

4 HPV vaccines are not covered as a preventive benefit by Priority Health individual plans. 

5 Re the shortage of Merck vaccine Recombivax for adults: Priority Health does not reimburse claims billed for adults receiving Hepatitis B vaccines when coded with the pediatric CPT code 90744. We have not located any documentation that doubling up on a pediatric formulation of a vaccine is recommended to cover an adult. After review by our medical directors, we will not reimburse this vaccine at the pediatric level. These claims will continue to hit edits for age and/or exceed units. We recommend that providers switch to the Engerix-B® vaccines manufactured by Glaxo Smith Kline (GSK).