Vaccines and vaccine administration

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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.
Vaccines provided at no cost by the government are still billable but wouldn't be separately payable. Vaccine administration is payable.
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). Reported NDCs must be valid and match the vaccines administered.
# = Coverage of these vaccines will be evaluated once FDA approval granted
* = Special conditions. Certain vaccines will be allowed for payment for ages outside of the approved age range for conditions related to altered immunocompetence such as splenectomy, certain cancers, bone marrow transplant, renal disease, make-up for vaccines never received for standard age.
N/A = No product available to be billed with this code

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
90589	Chikungunya virus vaccine, live attenuated, for intramuscular use BN: IXCHIQ	NO	YES	NO
90593#	Chikungunya virus vaccine, recombinant, for intramuscular use	N/A	N/A	N/A
90611	Smallpox and monkeypox vaccine, attenuated vaccinia virus, live, non-replicating, preservative free, 0.5 mL dosage, suspension, for subcutaneous use Ages: 18 years & older BN: JYNNEOS	YES	YES (adults) VFC (children)	NO
90619	Meningococcal conjugate vaccine, serogroups A, C, W, Y, quadrivalent, tetanus toxoid carrier (MenACWY-TT), for intramuscular use Ages: 2 years & older BN: MenQuadfi	YES	YES (adults) VFC (children)	NO
90620	Meningococcal recombinant protein and outer membrane vesicle vaccine, Serogroup B (MenB-4C), 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 (MenB-FHbp), 2 or 3 dose schedule, for intramuscular use Ages: 10-25 years BN: TRUMENBA	YES	YES (adults) VFC (children)	NO
90622	Vaccinia (smallpox) virus vaccine, live, lyophilized, 0.3 mL dosage, for percutaneous use	NO	NO	NO
90623	Meningococcal pentavalent vaccine, conjugated Men A, C, W, Y-tetanus toxoid carrier, and Men B-FHbp, for intramuscular use Ages: 10-25 years BN: PENBRAYA	YES	YES (adults) VFC (children)	NO
90625	Cholera vaccine, live, adult dosage, 1 dose BN VAXCHORA	NO	YES (adults)	NO
90632	Hepatitis A vaccine (Hep A), adult dosage, for intramuscular use Ages: 19 years & older BN: HAVRIX, VAQTA	YES	YES (adults)	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
90637 #	Influenza virus vaccine, quadrivalent (qIRV), mRNA; 30 mcg/0.5 mL dosage, for intramuscular use Awaiting FDA approval	NO	NO	NO
90638 #	Influenza virus vaccine, quadrivalent (qIRV), mRNA; 60 mcg/0.5 mL dosage, for intramuscular use Awaiting FDA approval	NO	NO	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: 2 months - 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
90649	Human Papilloma virus vaccine, types 6, 11, 16, 18, quadrivalent (4vHPV4), 3 dose schedule, for intramuscular use BN: No product available	N/A	N/A	N/A
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
90651	Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 2 or 3 dose schedule, for intramuscular use. Ages: 9-45 years BN: GARDASIL 9	YES	YES (adults) VFC (children)	NO
90653	Influenza virus vaccine (IIV), inactivated, subunit, adjuvanted, for intramuscular use BN:FLUAD	YES	YES (adults) VFC (children)	YES
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, FLUZONE, FLUVARIX, FLULAVAL	YES	YES (adults) VFC (children)	YES
90657	Influenza virus vaccine, trivalent (IIV3), split virus, for intramuscular use BN: AFLURIA, FLUZONE	YES	YES (adults) VFC (children)	YES
90658	Influenza virus vaccine, trivalent (IIV3), split virus, 0.5ml dose, for intramuscular use BN: AFLURIA, FLUZONE	YES	YES (adults) VFC (children)	YES
90660	Influenza virus vaccine, trivalent, live, for intranasal use BN: FLUMIST	YES	YES (adults) VFC (children)	YES
90661	Influenza virus vaccine, trivalent (ccIIV3), derived from cell cultures, subunit, antibiotic free, 0.5ml dosage for intramuscular use BN: FLUCELVAX	YES	YES (adults) VFC (children)	YES
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) BN: No product available	N/A	N/A	N/A
Q2035	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: No product available	N/A	N/A	N/A
Q2037	Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (FLUVIRIN) BN: No product available	N/A	N/A	N/A
Q2038	Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone) BN: FLUZONE	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: FLUCELVAX	YES	YES (adults) VFC (children)	YES
90670	Pneumococcal conjugate vaccine, 13 valent, for intramuscular use BN: No product available	N/A	N/A	N/A
90671	Pneumococcal conjugate vaccine, 15 valent (PCV15), for intramuscular use Ages: 6 weeks & older BN: VAXNEUVANCE	YES	YES	YES
90672	Influenza virus vaccine, quadrivalent (LAIV4), live, for intranasal use BN: No product available	N/A	N/A	N/A
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	YES	YES (adults) VFC (children)	YES
90674	Influenza virus vaccine, quadrivalent (ccIIV4), 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
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
90677	Pneumococcal conjugate vaccine, 20 valent (PCV20), for intramuscular use Ages: 6 weeks & older BN: PREVNAR 20	YES	YES (adults) VFC (children)	YES
90678	Respiratory syncytial virus vaccine, preF, subunit, bivalent, for intramuscular use (Code Price is per dose = 0.5 mL) Ages: 60 years & older, pregnant women BN: ABRYSVO	YES	YES	NO
90679	Respiratory syncytial virus vaccine, preF, recombinant, subunit, adjuvanted, for intramuscular use (Code Price is per dose = 0.5 mL) Ages: 60 years & older BN: AREXVY	YES	YES	NO
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
90682	Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use BN: No product available	N/A	N/A	N/A
90683	Respiratory syncytial virus vaccine, mRNA lipid nanoparticles, for intramuscular use Ages: 60 years & older BN: MRESVIA	NO	YES	NO
90684	Pneumococcal conjugate vaccine, 21 valent (PCV21), for intramuscular use Ages: 18 years & older BN: CAPVAXIVE	YES	YES	YES
90685	Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25ml dose for intramuscular use BN: No product available	N/A	N/A	N/A
90686	Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5ml dose for intramuscular use BN: No product available	N/A	N/A	N/A
90687	Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25ml dose for intramuscular use BN: No product available	N/A	N/A	N/A
90688	Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5ml dose for intramuscular use BN: No product available	N/A	N/A	N/A
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	YES	NO
90694	Influenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, preservative free, 0.5 mL dosage, for intramuscular use BN: No active product	N/A	N/A	N/A
90695 #	Influenza virus vaccine, H5N8, derived from cell cultures, adjuvanted, for intramuscular use Awaiting FDA approval	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 Age: 6 weeks through 4 years BN:VAXELIS	YES	VFC only	NO
90698	Diphtheria, tetanus toxoids, acellular pertussis vaccine, Haemophilus influenza Type b, and inactivated poliovirus vaccine (DtaP-IPV/Hib), for intramuscular use Ages: 6 weeks to 4 years 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 BN: No product available	N/A	N/A	N/A
90707	Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use Ages: 12 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: TDVAX, 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 (adults) VFC (children)	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, STAMARIL	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, W, Y, quadrivalent (MenACWY-CRM), for intramuscular use BN: MENACTRA; Ages: 9 months to 55 years MENVEO; Ages: 2 months to 55 years	YES	YES (adults) VFC (children)	NO
90736	Zoster (shingles) vaccine, live (HZV), for subcutaneous injection BN: No Active Product	N/A	N/A	N/A
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	YES (adults) VFC (children)	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	VFC only	YES
90744	Hepatitis B vaccine (HepB), pediatric/adolescent dosage (3 dose schedule), for intramuscular use Ages: 0-18 years BN: ENGERIX B, RECOMBIVAX HB	YES	YES (adults) VFC (children)	YES
90746	Hepatitis B vaccine (HepB), 3 dose schedule, for intramuscular use Ages: 11 years & older BN: RECOMBIVAX HB, ENGERIX B	YES	YES	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 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: 18 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 BN: No product available	N/A	N/A	N/A
90758	Zaire ebolavirus vaccine, live, for intramuscular use	NO	NO	NO
90759	Hepatitis B vaccine (HepB), 3-antigen (S, Pre-S1, Pre-S2), 10 mcg dosage, 3 dose schedule, for intramuscular use Ages: 18 years & older BN: PREHEVBRIO	YES	YES (adults) VFC (children)	YES
Code	Description	HMO/EPO, POS, PPO	Medicaid/Healthy Michigan Plan	Medicare Advantage Plans
91304	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, recombinant spike protein nanoparticle, saponin-based adjuvant, 5 mcg/0.5mL dosage, for intramuscular use (Novavax) Ages: 12 years & up	YES	YES (adults) VFC (children)	YES
91318	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, 3 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use (Pfizer) Ages: 6 months to 4 years	YES	VFC only	YES
91319	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, 10 mcg/0.2 mL dosage, tris-sucrose formulation, for intramuscular use (Pfizer) Ages: 5 to 11 years	YES	VFC only	YES
91320	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, 30 mcg/0.3 mL dosage, tris-sucrose formulation, for intramuscular use (Pfizer) Ages: 12 years & older BN: COMIRNATY	YES	YES (adults) VFC (children)	YES
91321	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, 25 mcg/0.25 mL dosage, for intramuscular use (Moderna) Ages: 6 months to 11 years	YES	VFC only	YES
91322	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, 50 mcg/0.5 mL dosage, for intramuscular use (Moderna) Ages: 12 years & older	YES	YES (adults) VFC (children)	YES

The following codes are not vaccines, they are monoclonal antibodies recommended by ACIP for use as prevention treatment:
90380	Respiratory syncytial virus, monoclonal antibody, seasonal dose; 0.5 mL dosage, for intramuscular use Ages: 0-24 months BN: Beyfortus	YES (Prior authorization required for patients over 8 months)	NO (Adults) VFC (Children)	YES (Prior authorization required)
90381	Respiratory syncytial virus, monoclonal antibody, seasonal dose; 1 mL dosage, for intramuscular use Ages 0-24 months BN: Beyfortus	YES (Prior authorization required for patients over 8 months)	NO (Adults) VFC (Children)	YES (Prior authorization required)