Influenza vaccine coverage

  • Pre-authorization requirements for flu vaccines are waived for all HMO, POS, PPO and MyPriority® plan members for out-of-network providers.
  • Self-funded plan coverage will vary by employer group, depending on purchase of coverage for general immunizations, flu shots and pharmacy benefits. Self-funded plans may also place additional restrictions on member use of out-of-network providers.
  • Coinsurance and out-of-network benefits may apply. Reference plan documents for details.
  • Vaccine shortages: In the event of a vaccine shortage, Priority Health will issue written guidelines and post them on this website. Note: A shortage is not the same as a delay from your vendor.

Jump down to Coverage by location

Flu vaccine coverage by plan, effective 08/01/2018

Codes Description HMO/EPO, POS,
PPO
Medicaid & Healthy Michigan Plan Medicare Advantage plans
90630

Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use
Ages 18-64 only
BN: FLUZONE INTRADERMAL QUADRIVALENT

Covered Covered Covered by Medicare Parts A & B
90653 Influenza virus vaccine, inactivated (IIV), subunit, adjuvanted, for intramuscular use
Ages 65 years and older
BN: FLUAD 
Covered Covered Covered by Medicare Parts A & B
90654 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, for intradermal use
Ages 18-64 only
BN: No product available
N/A N/A N/A
90655 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25mL dosage, for intramuscular use
BN: No product available
N/A N/A N/A
90656
Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, for 0.5mL dosage, for intramuscular use
BN: AFLURIA (2) PF (ages 5 years and older)
FLUVIRIN PF (ages 4 years and older)
Covered Adults: Covered
Children: VFC
Covered by Parts A & B
90657 Influenza virus vaccine, trivalent (IIV3), split virus, 0.25mL dosage, for intramuscular use
BN: No product available
N/A N/A N/A
90658
Influenza virus vaccine, trivalent (IIV3), split virus, 0.5mL dosage, for intramuscular use
BN: AFLURIA (2) (ages 5 years and older)
FLUVIRIN (ages 4 years and older)
Covered Adults: Covered
Children: VFC
Not covered; use a vaccine-specific Q code.
90660 Influenza virus vaccine, trivalent (LAIV3), live, for intranasal use
BN: No active NDC for this code
N/A N/A N/A
90661 Influenza virus vaccine (ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, 0.5mL dosage, 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 years & older only
BN: FLUZONE HIGH DOSE
Covered Covered Covered by Parts A & B
90664 Influenza virus vaccine, live (LAIV) pandemic formulation, for intranasal use
BN: No product available
N/A N/A N/A
90666
Note 1
Influenza virus vaccine (IIV), pandemic formulation, split virus, preservative free, for intramuscular use NO NO NO
90667
Note 1
Influenza virus vaccine (IIV), pandemic formulation, split virus, adjuvanted, for intramuscular use
NO NO NO
90668
Note 1
Influenza virus vaccine (IIV), pandemic formulation, split virus, for intramuscular use
NO NO NO
90672 Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use
Ages 2-49 only
BN: FLUMIST QUADRIVALENT
Covered Not covered Not covered
90673 Influenza virus vaccine, trivalent (RIV3), derived from recombinant DNA (RIV3), hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use
Ages 18 years and older 
BN: FLUBLOK
Not covered Covered Covered by Parts A & B
90674 Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use
Ages 4 years and older
BN: FLUCELVAX QUADRIVALENT
Covered Adults: Covered
Children: VFC
Covered by Parts A & B 
90682
Note 2
Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use
Ages 18 years and older
BN: FLUBLOK QUADRIVALENT
Not covered Not covered Covered by Parts A & B
90685 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL dosage, for intramuscular use
Ages 6-35 months
BN: FLUZONE QUADRIVALENT
Covered VFC only Covered by Parts A & B
90686 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5mL dosage, for intramuscular use
BN: FLUZONE QUADRIVALENT (ages 3 years and older)
FLUARIX QUADRIVALENT (ages 3 years and older)
AFLURIA QUADRIVALENT (ages 18 years and older)
FLULAVAL (ages 6 months and older)
Covered Adults: Covered
Children: VFC
Covered by Parts A & B
90687 Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25mL dosage, for intramuscular use
Ages 6 months and older
BN: FLUZONE QUADRIVALENT
Covered Adults: Covered
Children: VFC
Covered by Parts A & B
90688 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5mL dosage, for intramuscular use
Ages 6 months and older
BN: FLULAVAL QUADRIVALENT, FLUZONE QUADRIVALENT
Covered Adults: Covered
Children: VFC
Covered by Parts A & B
90756 Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5mL dosage, for intramuscular use
Ages 4 years and older
BN: FLUCELVAX QUADRIVALENT
Covered Adults: Covered
Children: VFC
Covered by Parts A & B
Q2034 Influenza virus vaccine, split virus, for intramuscular use (AGRIFLU)
Ages: 18 years and older
BN: No active NDS for this code
N/A N/A N/A
Q2035
Note 3
Influenza virus vaccine, split virus, when admnistered to individuals 3 years of age and older, for intramuscular use (AFLURIA)
BN: AFLURIA
Covered Adults: Covered
Children: VFC
Covered by Parts A & B
Q2036 Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use (FLULAVAL)
BN: FLULAVAL, no current NDC
Covered Adults: Covered
Children: VFC
Covered by Parts A & B
Q2037 Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use (FLUVARIN)
BN: FLUVARIN
Covered Adults: Covered
Children: VFC
Covered by Parts A & B
Q2038 Influenza virus vaccine, split virus, for use in individuals 3 years of age and older, for intramuscular use (FLUZONE)
BN: No current NDC
Covered Adults: Covered
Children: VFC
Covered by Parts A & B
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
Covered Adults: Covered
Children: VFC
Covered by Parts A & B

Flu vaccine administration coverage by plan

Administration codes Description HMO/EPO, POS,
PPO
Medicaid & Healthy Michigan Plan Medicare Advantage
90460
90461
90471
90472
90473
90474
CPT codes for vaccine administration. (See description to select the most appropriate code) Covered1 Covered1

Not covered1

See G codes

1 Office copay usually does not apply if vaccine administration is the only service rendered.
G0008 HCPCS code for seasonal flu vaccine administration for Medicare patients Not covered2 Not covered2

REQUIRED under Parts A & B

2 Office copay usually does not apply if vaccine administration is the only service rendered.

Seasonal flu vaccine coverage by location

Location HMO or EPO POS

Preferred benefit for in-network providers

Alternate benefit for out-of-network providers

PPO

In-network benefit for in-network providers

Out-of-network benefit for out-of-network providers

Medicaid & Healthy Michigan Plan Medicare Advantage
Physician office Covered Covered Covered

Covered

VFC restrictions apply

Covered by Parts A & B

Community clinics Covered Covered Covered

Covered

VFC restrictions apply

Covered by Parts A & B

In-network providers must bill us directly. Member cannot file a claim form for reimbursement.
Commercial plans: Out-of-network providers may bill us or member can pay and file for reimbursement.
Priority Health Medicare Advantage plan members: Cost is $0 in any out-of-network setting. Non-contracted providers should bill Priority Health.
Home health care services Covered if the health care organization contracts with us and bills us directly. The cost for administration is included in the cost of the nursing visit.
Health departments Covered Covered Covered Covered

No member reimbursement; provider must bill

VFC restrictions apply

Covered by Parts A & B
In-network providers must bill us directly. Member cannot file a claim form for reimbursement.
Commercial plans: Out-of-network providers may bill us or member can pay and file for reimbursement.
Priority Health Medicare Advantage members: Cost is $0 in any out-of-network setting. Non-contracted providers should bill Priority Health.
Pharmacies that participate in the Express Scripts network Covered3 Covered3 Covered3 Covered for members age 19 and over Covered by Parts A & B

3 Commercial member must have prescription coverage. Pharmacy will bill us directly.
Priority Health Medicare Advantage members: Covered under medical benefit. Pharmacy will bill us.

Pharmacies that don't participate Member can pay and file for reimbursement.
Urgent care centers Covered Covered Covered Covered

VFC restrictions apply

Covered by Parts A & B
If the center contracts with Priority Health, it must bill us directly. Member cannot file a claim form for reimbursement.
Commercial plans: Out-of-network providers may bill us or member can pay and file for reimbursement.
Priority Health Medicare Advantage members:  Cost is $0 in any out-of-network setting. Non-contracted providers should bill Priority Health.
Urgent care copay will not apply if only service is flu vaccine.
Work site flu clinic Covered Covered Covered Not applicable Not applicable
Covered if the provider contracts with Priority Health and bills us directly; member cannot file for reimbursement.
Not covered if the employer has a discount arrangement with the provider (even if contracted) and the provider will be paid directly by the employer. Member cannot file a claim form for reimbursement.

Notes

1 Coverage of these vaccines will be evaluated once FDA approval is granted.

2 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.

3 The CDC recommends special consideration when administering AFLURIA for children ages 5 to less than 9 years of age. See package insert or visit the Afluria website.