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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, | Medicaid /Healthy Michigan Plan | Medicare |
---|---|---|---|---|
90476 | Adenovirus vaccine, type 4, live, for oral use | N/A | N/A | N/A |
90477 | Adenovirus vaccine, type 7, live, for oral use | N/A | N/A | N/A |
90581 | Anthrax vaccine, for subcutaneous use | NO | NO | NO |
90585 | Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for percutaneous use | YES | NO | NO |
90586 | Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, for intravesical use | 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 | YES | YES (adults) | NO |
90619 | Meningococcal conjugate vaccine, serogroups A, C, W, Y, quadrivalent, tetanus toxoid carrier (MenACWY-TT), for intramuscular use | YES | YES (adults) | NO |
90620 | Meningococcal recombinant protein and outer membrane vesicle vaccine, Serogroup B (MenB-4C), 2 dose schedule, for intramuscular use | YES | YES (adults) | NO |
90621 | Meningococcal recombinant lipoprotein vaccine, Serogroup B (MenB-FHbp), 2 or 3 dose schedule, for intramuscular use | YES | YES (adults) | 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 | YES | YES (adults) | NO |
90625 | Cholera vaccine, live, adult dosage, 1 dose | NO | YES (adults) | NO |
90632 | Hepatitis A vaccine (Hep A), adult dosage, for intramuscular use | YES | YES (adults) | Covered under Medicare Part B only for the following diagnoses: |
90633 | Hepatitis A vaccine (Hep A), pediatric/adolescent dosage - 2 dose schedule, for intramuscular use | YES | VFC only | Covered under Medicare Part B only for the following diagnoses: |
90634 | Hepatitis A vaccine (Hep A), pediatric/adolescent dosage-3 dose schedule, for intramuscular use | N/A | N/A | N/A |
90636 | Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use | YES | YES (adults) | 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 | N/A | N/A | N/A |
Code | Description | HMO/EPO, | Medicaid /Healthy Michigan Plan | Medicare |
90647 | Hemophilus influenza b vaccine (Hib), PRP-OMP conjugate (3 dose schedule), for intramuscular use | YES | VFC only | NO |
90648 | Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for intramuscular use | YES | VFC only | NO |
90649 | Human Papilloma virus vaccine, types 6, 11, 16, 18, quadrivalent (4vHPV4), 3 dose schedule, for intramuscular use | N/A | N/A | N/A |
90650 | Human Papillomavirus (HPV) vaccine, types 16 and 18, bivalent (2vHPV), 3 dose schedule, for intramuscular use | 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. | YES | YES (adults) | NO |
90653 | Influenza virus vaccine (IIV), inactivated, subunit, adjuvanted, for intramuscular use | YES | YES (adults) | YES |
90655 | Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25 dosage for intramuscular use | N/A | N/A | N/A |
90656 | Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5ml dose, for intramuscular use | YES | YES (adults) | YES |
90657 | Influenza virus vaccine, trivalent (IIV3), split virus, for intramuscular use | YES | YES (adults) | YES |
90658 | Influenza virus vaccine, trivalent (IIV3), split virus, 0.5ml dose, for intramuscular use | YES | YES (adults) | YES |
90660 | Influenza virus vaccine, trivalent, live, for intranasal use | YES | YES (adults) | YES |
90661 | Influenza virus vaccine, trivalent (ccIIV3), derived from cell cultures, subunit, antibiotic free, 0.5ml dosage for intramuscular use | YES | YES (adults) | YES |
90662 | Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use | YES | YES | YES |
90664 | Influenza virus vaccine, live (LAIV) pandemic formulation, live, for intranasal use | 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, | Medicaid /Healthy Michigan Plan | Medicare |
Q2034 | Agriflu influenza virus vaccine, split virus, for intramuscular use (AGRIFLU) | 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) | YES | YES (adults) | YES |
Q2036 | Flulaval influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (FLULAVAL) | 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) | 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) | YES | YES (adults) | YES |
Q2039 | Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified) | YES | YES (adults) | YES |
90670 | Pneumococcal conjugate vaccine, 13 valent, for intramuscular use | N/A | N/A | N/A |
90671 | Pneumococcal conjugate vaccine, 15 valent (PCV15), for intramuscular use | YES | YES | YES |
90672 | Influenza virus vaccine, quadrivalent (LAIV4), live, for intranasal use | 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 | YES | YES (adults) | YES |
90674 | Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5mL dosage, for intramuscular use | N/A | N/A | N/A |
90675 | Rabies vaccine, for intramuscular use | YES | YES | Covered under Medicare Part B only for the following diagnoses: |
90676 | Rabies vaccine, for intradermal use | N/A | N/A | N/A |
90677 | Pneumococcal conjugate vaccine, 20 valent (PCV20), for intramuscular use | YES | YES (adults) | YES |
90678 | Respiratory syncytial virus vaccine, preF, subunit, bivalent, for intramuscular use (Code Price is per dose = 0.5 mL) | YES | YES | NO |
90679 | Respiratory syncytial virus vaccine, preF, recombinant, subunit, adjuvanted, for intramuscular use (Code Price is per dose = 0.5 mL) | YES | YES | NO |
90680 | Rotavirus vaccine, pentavalent (RV5), 3 dose schedule, live, for oral use | YES | VFC only | NO |
90681 | Rotavirus vaccine, human, attenuated (RV1), 2 dose schedule, live, for oral use | 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 | N/A | N/A | N/A |
90683 | Respiratory syncytial virus vaccine, mRNA lipid nanoparticles, for intramuscular use | NO | YES | NO |
90684 | Pneumococcal conjugate vaccine, 21 valent (PCV21), for intramuscular use | YES | YES | YES |
90685 | Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25ml dose for intramuscular use | N/A | N/A | N/A |
90686 | Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5ml dose for intramuscular use | N/A | N/A | N/A |
90687 | Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25ml dose for intramuscular use | N/A | N/A | N/A |
90688 | Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5ml dose for intramuscular use | N/A | N/A | N/A |
90689 | Influenza virus vaccine quadrivalent (IIV4), inactivated, adjuvanted, preservative free, 0.25 mL dosage, for intramuscular use | N/A | N/A | N/A |
Code | Description | HMO/EPO, | Medicaid /Healthy Michigan Plan | Medicare |
90690 | Typhoid vaccine, live, oral | NO | NO | NO |
90691 | Typhoid vaccine, Vi capsular polysaccharide (ViCPs), for intramuscular use | NO | YES | NO |
90694 | Influenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, preservative free, 0.5 mL dosage, for intramuscular use | 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 | 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 | 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 | YES | VFC only | NO |
90700 | Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), for use in individuals younger than 7 years, for intramuscular use | YES | VFC only | NO |
90702 | Diphtheria and tetanus toxoids adsorbed (DT) for use in individuals younger than 7 years, for intramuscular use | N/A | N/A | N/A |
90707 | Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use | YES | YES (adults) | NO |
90710 | Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use | YES | VFC only | NO |
Code | Description | HMO/EPO, | Medicaid /Healthy Michigan Plan | Medicare |
90713 | Poliovirus vaccine, inactivated, (IPV), for subcutaneous or intramuscular use | YES | YES (adults) | NO |
90714 | Tetanus and diphtheria toxoids adsorbed (Td), preservative free, for use in individuals, for intramuscular use | YES | YES (adults) | 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 | YES | YES (adults) | 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 | YES | YES (adults) | NO |
90717 | Yellow fever vaccine, live, for subcutaneous use | NO | NO | NO |
90723 | Diphtheria, tetanus toxoids, acellular pertussis vaccine, hepatitis B, and inactivated poliovirus vaccine (DtaP-HepB-IPV), for intramuscular use | YES | VFC only | NO |
Code | Description | HMO/EPO, | Medicaid /Healthy Michigan Plan | Medicare |
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 | YES | YES (adults) | YES |
90733 | Meningococcal polysaccharide vaccine serogroups A,C, Y, W-135, quadrivalent (MenACWY), for subcutaneous use | N/A | N/A | N/A |
90734 | Meningococcal conjugate vaccine, serogroups A, C, W, Y, quadrivalent (MenACWY-CRM), for intramuscular use | YES | YES (adults) | NO |
90736 | Zoster (shingles) vaccine, live (HZV), for subcutaneous injection | N/A | N/A | N/A |
90738 | Japanese encephalitis virus vaccine, inactivated, for intramuscular use | NO | NO | NO |
90739 | Hepatitis B vaccine (HepB), adult dosage (2 dose schedule), for intramuscular use | YES | YES (adults) | YES |
90740 | Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use | YES | YES (adults) | YES |
90743 | Hepatitis B vaccine (HepB), adolescent (2 dose schedule), for intramuscular use | YES | VFC only | YES |
90744 | Hepatitis B vaccine (HepB), pediatric/adolescent dosage (3 dose schedule), for intramuscular use | YES | YES (adults) | YES |
90746 | Hepatitis B vaccine (HepB), 3 dose schedule, for intramuscular use | YES | YES | YES |
90747 | Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use | YES | YES (adults) | YES |
90748 | Hepatitis B and Hemophilus influenza b vaccine (Hib-HepB), for intramuscular use | N/A | N/A | N/A |
90749 | Unlisted vaccine/toxoid | YES | YES | NO |
90750 | Zoster (shingles) vaccine (HZV), recombinant, sub-unit, adjuvanted, for intramuscular injection | YES | YES | NO |
90756 | Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5ml dose, for intramuscular use | 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 | YES | YES (adults) | 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) | YES | YES (adults) | 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) | 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) | 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) | YES | YES (adults) | 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) | 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) | YES | YES (adults) | 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 | YES (Prior authorization required for patients over 8 months) | NO (Adults) | YES (Prior authorization required) |
90381 | Respiratory syncytial virus, monoclonal antibody, seasonal dose; 1 mL dosage, for intramuscular use | YES (Prior authorization required for patients over 8 months) | NO (Adults) | YES (Prior authorization required) |