Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 10|15|2007 POLICY LAST REVIEWED: 10|27|2025

OVERVIEW This policy documents payment and claims filing guidelines for immunizations and vaccinations provided for pediatric and adult members. MEDICAL CRITERIA Not applicable

PRIOR AUTHORIZATION
Not applicable

POLICY STATEMENT Medicare Advantage Plans The following vaccines are covered under the member’s Part B Medicare Benefit:
 Pneumococcal pneumonia
 Influenza virus
 COVID-19  Hepatitis B for individuals at high or intermediate risk (Requires ICD-10-CM diagnosis code Z23)
 Other vaccines when directly related to the treatment of an injury or direct exposure to a disease or condition, such as rabies and tetanus.

Note: to ensure correct claims processing for Tetanus Vaccine coverage under Part B, the claim must be filed with a diagnosis that indicates that the vaccine was needed due to an injury.

All other vaccines not included in the list above are covered under the member’s Part D Medicare Drug Benefit Plan.

Commercial Products Vaccinations/immunizations are covered when recommended by the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) and when US Food and Drug Administration (FDA) guidelines are met.

In adherence with the Rhode Island General Law 27-18-86, BCBSRI will continue to waive cost-share (e.g. co-pays and/or deductibles) for immunizations related to COVID-19 in and out of network for fully insured and municipal self-funded employer groups.

Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for the applicable Adult Preventive Immunizations and/or Pediatric Preventive Immunization benefits/coverage. Biologicals Supplied by the States

Rhode Island The State of Rhode Island Department of Health (DOH) provides biologicals for pediatric immunizations for members residing in Rhode Island. Blue Cross & Blue Shield of Rhode Island (BCBSRI) does not provide reimbursement to the provider for biologicals for immunizations that are supplied by the DOH or any other state or federal agency. BCBSRI follows the DOH guidelines when determining which vaccines are
Payment Policy | Immunizations Adult and Pediatric

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state supplied. BCBSRI is assessed a vaccine tax, which is paid to the State of Rhode Island in order for the DOH to fund the vaccine distribution program. Refer to the DOH for more information on state-supplied vaccines as well as information on any vaccine shortages.

The Rhode Island DOH Pediatric and Adult State Supplied Vaccines are listed here:

https://health.ri.gov/publications/guidelines/PediatricAndAdultStateSuppliedVaccine.pdf

All Other States For out-of-state members, providers must refer to the applicable state guidelines for state-supplied vaccines.

Non-State-Supplied Vaccines Purchased by the Provider Providers must submit both the administration procedure code and vaccine/toxoid procedure code and append modifier 22 on the claim. Modifier 22 identifies the vaccine as non-state supplied and indicates the vaccine was supplied by the physician, which facilitates pricing of the claim to include allowance for the vaccine.

Additional Claims Filing Information:  State-supplied immunization claims must be filed using the appropriate administration and vaccine codes.  Evaluation & Management (E/M) services should not be filed along with the immunization unless the E/M represents a separately identifiable service and modifier 25 is appended to the E/M code.

Clinics and Preventive Immunizations
BCBSRI’s Commercial plans cover immunizations, including those related to travel. This includes biological/vaccine and vaccine administrations. Vaccine administration codes include very limited counseling regarding the specific vaccine. The services related to additional counseling of a patient about their preventive or prophylactic medicine/vaccination needs, safety, exposure risks while traveling, etc. are not covered services.

While not covered, travel clinic counseling services are typically reported using codes 99401 to 99404 (individual) or 99411 to 99412 (group). Travel Clinics must notify members of their financial obligation and may bill the member for these noncovered counseling services. Members should be made aware of this denial at the time the service is rendered. Append modifier GU or GX for Commercial products. Physicians/professional providers and institutional providers are not required to submit claims for these services in order to bill the member.

Medicare Advantage Plans do not cover vaccines related to travel, except as provided by Part D. This exclusion also applies to the vaccine administration service.

Immunizations for School or Employment
Immunizations, as a requirement for school or employment or related to an employment exposure, are considered a contract exclusion for Medicare Advantage Plans and Commercial products.

Vaccine Retail Program:
Rhode Island-based pharmacies choosing to participate in the BCBSRI program may submit claims directly in the following instances:

For Medicare Advantage Plan members: • Flu administration only
• Shingles vaccine administration and supply • Pneumococcal vaccine administration and supply • Respiratory syncytial virus (RSV) administration and supply

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There is no out of pocket expense for the flu and pneumonia vaccines and administration as these are considered Part B drugs. There is no out of pocket expense for Shingles, RSV vaccine, or any other Part D adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) according to IRA guidance.

For Commercial members: • Flu administration and supply • Covid-19 vaccine and administration • Respiratory syncytial virus (RSV) vaccine and administration • Shingles vaccine administration and supply

Pneumococcal vaccines are not submitted under the Vaccine Retail Program for Commercial
products. Members are responsible for payment and may submit a request to Blue Cross for coverage. For any other vaccine not noted above, the member is responsible for payment and may submit a
request to Blue Cross for coverage.

COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for the applicable Adult Preventive Immunizations and/or Pediatric Preventive Immunization benefits/coverage.

BACKGROUND The Rhode Island General Law (RIGL) § 27-38.1-2: Insurance Coverage for Pediatric Preventive Care is stated below: (a) Every health insurance plan providing coverage for a dependent or minor child, other than school policies, shall include benefits for pediatric preventive care. All benefits shall be reimbursed in accordance with the reimbursement policies and procedure of each health insurer.
(b) Every health insurer shall provide benefits for pediatric preventive care or make that care available to its enrolled participants. Benefits do not need to be provided pursuant to this section for pediatric preventive care services that are paid for or offered free of charge by the state of Rhode Island. Benefits do not need to be provided for the cost of biologicals used for vaccinations.

Immunization is the process of stimulating the body’s immune system to protect against a specific infection. Minute amounts of the specific bacteria or virus, in whole or part, are specially treated so that when given to the patient, they will stimulate the body's immune system without actually causing disease. Some immunizations require “booster,” or repeat doses of the same vaccine to keep up the body’s protection against a specific bacteria or virus.

The Rhode Island DOH provides certain biologicals for physician’s offices and hospital pharmacies at no charge for residents of Rhode Island who meet the Rhode Island DOH vaccine distribution guidelines.

With the advent of the Medicare Part D program, there is now broader reimbursement available to providers for vaccines administered to Medicare beneficiaries. Some vaccines are covered under Medicare Part B and others under Part D. The Part B program covers limited vaccines indicated for the Medicare population, with the provider administering the vaccine and billing the Part B contractor (Medicare carrier or Part A/B Medicare Administrative Contractor or A/B MAC) for both the vaccine and its associated administration.
Medicare Part B currently covers the following immunizations:  Pneumococcal pneumonia vaccine.  Influenza virus vaccine.  COVID-19 vaccine.  Hepatitis B vaccine for individuals at high or intermediate risk; and  Other vaccines when directly related to the treatment of an injury or direct exposure to a disease or condition, such as rabies and tetanus.

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM

The Part D program will generally cover those vaccines not available for reimbursement under Medicare Parts A or B when administration is reasonable and necessary for the prevention of illness. Part D plans identify covered drugs and vaccines through the use of formularies. However, a new preventative vaccine may not be specifically listed on the Part D plan’s formulary. This does not mean the vaccine is not available for reimbursement. The provider can contact the Part D plan about coverage and any supporting information that might be necessary to facilitate vaccine coverage for the beneficiary.

CODING

The following CPT administration codes are covered for Medicare Advantage Plans and Commercial products:

90460 Immunization administration through 18 years of age via any route of administration,

         with counseling by a physician or other qualified health care professional (applies to NP, PA  
         with NPI): first vaccine/toxoid component

90461 Immunization administration through 18 years of age via any route of administration,

         with counseling by a physician or other qualified health care professional (applies to NP, PA 
         with NPI): each additional vaccine/toxoid component

90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or

         intramuscular injections); one vaccine (single or combination vaccine/toxoid)

90472 Immunization administration (includes percutaneous, intradermal, subcutaneous, or

          intramuscular injections); each additional vaccine single or combination vaccine/toxoid)

90473 Immunization administration by intranasal or oral route; one vaccine (single or

         combination vaccine/toxoid)

90474 Immunization administration by intranasal or oral route; each additional vaccine

         (single or combination vaccine/toxoid)

90480 Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, single dose 90612 Influenza virus vaccine, trivalent, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, 31.7 mcg/0.32 mL dosage, for intramuscular use 90613 Influenza virus vaccine, quadrivalent, and severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, 40 mcg/0.4 mL dosage, for intramuscular use 96380 Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramuscular injection, with counseling by physician or other qualified health care professional 96381 Administration of respiratory syncytial virus, monoclonal antibody, seasonal dose by intramuscular injection

Note: Claims filed for multiple vaccines administered on the same date of service and by the same provider should be filed using the administration add-on codes (90461, 90472, or 90474) and indicating the number of units used.

Medicare Advantage Plans The following CPT/HCPCS vaccine/toxoid codes are covered as a Part B benefit: 90380 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 0.5 mL dosage, for intramuscular use 90381 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 1 mL dosage, for intramuscular use 90611 Smallpox and monkeypox vaccine, attenuated vaccinia virus, live, non-replicating, preservative free, 0.5 mL dosage, suspension, for subcutaneous use; for use in patients aged 18 years and older 90622 Vaccinia (smallpox) virus vaccine, live, lyophilized, 0.3 mL dosage, for percutaneous use; for patients aged 12 months and older
90626 Tick-borne encephalitis virus vaccine, inactivated: 0.25 mL dosage, for intramuscular use
effective 7/1/2022

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 5 (401) 274-4848 WWW.BCBSRI.COM

90627 Tick-borne encephalitis virus vaccine, inactivated: 0.5 mL dosage, for intramuscular use effective 7/1/2022(deleted by CPT effective 1/1/2025) 90635 Influenza virus vaccine, H5N1, (New Avian Flu vaccine) derived from cell cultures, adjuvanted,
for intramuscular use 90637 Influenza virus vaccine, quadrivalent (qIRV), mRNA; 30 mcg/0.5 mL dosage, for intramuscular use
90638 Influenza virus vaccine, quadrivalent (qIRV), mRNA; 60 mcg/0.5 mL dosage, for intramuscular use
90653 Influenza virus vaccine, inactivated, subunit, adjuvanted, for intramuscular use
(deleted by CPT effective 1/1/2025) 90655 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25 mL dosage,

         for intramuscular use

90656 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 mL dosage,

         for intramuscular use

90657 Influenza virus vaccine, trivalent (IIV3), split virus, 0.25 mL dosage, for intramuscular use
90658 Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for intramuscular use
90660 Influenza virus vaccine, trivalent, live (LAIV3), for intranasal use
90661 Influenza virus vaccine, trivalent (ccIIV3), derived from cell cultures, subunit, preservative

         and antibiotic free, 0.5 mL dosage, for intramuscular use

90662 Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via

          increased antigen content, for intramuscular use

90664 Influenza virus vaccine, live (LAIV), pandemic formulation, for intranasal use
90670 Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use
90671 Pneumococcal conjugate vaccine, 15 valent (PCV15), for intramuscular use (Effective 7/1/2021) 90672 Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use
90673 Influenza virus vaccine, trivalent (RIV3), derived from recombinant DNA, hemagglutinin

         (HA) protein only, preservative and antibiotic free, for intramuscular use

90674 Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative

         and antibiotic free, 0.5 mL dosage, for intramuscular use

90675 Rabies vaccine, for intramuscular use
90676 Rabies vaccine, for intradermal use
90677 Pneumococcal conjugate vaccine, 20 valent (PCV20), for intramuscular use (Effective 7/1/2021) 90678 Respiratory syncytial virus (RSV) vaccine, preF, subunit, bivalent, for intramuscular use (Effective 10/1/2023) 90679 Respiratory syncytial virus vaccine, preF, recombinant, subunit, adjuvanted, for intramuscular use (Effective 10/1/2023) 90682 Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA,

         hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use

90684 Pneumococcal conjugate vaccine, 21 valent (PCV21), for intramuscular use 90685 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL dosage,

         for intramuscular use

90686 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage,

         for intramuscular use

90687 Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25 mL dosage, for intramuscular use
90688 Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 mL dosage, for intramuscular use
90689 Influenza virus vaccine quadrivalent (IIV4), inactivated, adjuvanted, preservative free,

           0.25 mL dosage, for intramuscular use

90694 Influenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, preservative free, 0.5 mL

          dosage, for intramuscular use

90695 Influenza virus vaccine, H5N8, derived from cell cultures, adjuvanted, for intramuscular use

         (Avian bird flu)

90714 Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, for use in individuals seven years

          or older, for intramuscular use

90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine (TdaP), for use in individuals 7 years

          or older, for intramuscular use

90732 Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed

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          patient dosage, when administered to individuals 2 years or older, for subcutaneous or  
          intramuscular use

90739 Hepatitis B vaccine (HepB), adult dosage, 2 dose schedule, for intramuscular use 90740 Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 3 dose schedule,

          for intramuscular use

90743 Hepatitis B vaccine (HepB), adolescent, 2 dose schedule, for intramuscular use
90744 Hepatitis B vaccine (HepB), pediatric/adolescent dosage, 3 dose schedule, for intramuscular use
90746 Hepatitis B vaccine (HepB), adult dosage, 3 dose schedule, for intramuscular use
90747 Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 4 dose schedule,

          for intramuscular use

90748 Hepatitis B and Haemophilus influenzae type b vaccine (Hib-HepB), for intramuscular use
90750 Zoster (shingles) vaccine (HZV), recombinant, sub-unit, adjuvanted, for intramuscular injection

          (age 50 years of age and above includes the 2 dose vaccine)

90756 Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic

           free, 0.5mL dosage, for intramuscular use

90759 - Hepatitis B vaccine (HepB), 3-antigen (S, Pre-S1, Pre-S2), 10 mcg dosage, 3 dose schedule, for I

intramuscular use effective on July 1, 2022 91318 Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, 3 mcg/0.3 mL dosage, tris-sucrose formulation, for intramuscular use 91319 Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, 10 mcg/0.3 mL dosage, tris-sucrose formulation, for intramuscular use 91320 Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, 30 mcg/0.3 mL dosage, tris-sucrose formulation, for intramuscular use 91321 Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, 25 mcg/0.25 mL dosage, for intramuscular use 91322 Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, 50 mcg/0.5 mL dosage, for intramuscular use 91323 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, 10 mcg/0.2 mL dosage, for intramuscular use Q2034 In Influenza virus vaccine, split virus, for intramuscular use (Agriflu) Q2035 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older,

           for intramuscular use (Afluria)

Q2036 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older,

           for intramuscular use (Flulaval)

Q2037 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older,

           for intramuscular use (Fluvirin)

Q2038 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older,

           for intramuscular use (Fluzone)

For Medicare Part B coverage, and Commercial, the following diagnosis codes are required with the applicable CPT vaccine codes for Rabies or Hepatitis B for individuals at high or intermediate risk: ICD-10-CM Diagnosis Codes: Rabies: Z20.3 Contact with and (suspected) exposure to rabies
Note: for correct claims processing, place this diagnosis code in the first position on the claim form Hepatitis B: Z23 Encounter for immunization

Commercial Products
The following CPT/HCPCS vaccine/toxoid codes are covered:

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90380 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 0.5 mL dosage, for intramuscular use 90381 Respiratory syncytial virus, monoclonal antibody, seasonal dose; 1 mL dosage, for intramuscular use 90382 Respiratory syncytial virus, monoclonal antibody, seasonal dose, 0.7 mL, for intramuscular use 90476 Adenovirus vaccine, type 4, live, for oral use
90477 Adenovirus vaccine, type 7, live, for oral use
90581 Anthrax vaccine, for subcutaneous use 90587 Dengue vaccine, quadrivalent, live, 3 dose schedule, for subcutaneous use
90589 Chikungunya virus vaccine, live attenuated, for intramuscular use 90593 Chikungunya virus vaccine, recombinant, for intramuscular use 90611 Smallpox and monkeypox vaccine, attenuated vaccinia virus, live, non-replicating,

          preservative free, 0.5 mL dosage, suspension, for subcutaneous use; for use  
          in patients aged 18 years and older

90619 Meningococcal conjugate vaccine, serogroups A, C, W, Y, quadrivalent, tetanus toxoid

         carrier (MenACWY-TT), for intramuscular use

90620 Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B

         (MenB-4C), 2 dose schedule, for intramuscular use

90621 Meningococcal recombinant lipoprotein vaccine, serogroup B (MenB-FHbp), 2 or 3 dose

         schedule, for intramuscular use

90622 Vaccinia (smallpox) virus vaccine, live, lyophilized, 0.3 mL dosage, for percutaneous use; for patients aged 12 months and older
90623 Meningococcal pentavalent vaccine, conjugated Men A, C, W, Y- tetanus toxoid carrier, and Men B- FHbp, for intramuscular use 90624 Meningococcal pentavalent vaccine, Men B-4C recombinant proteins and outer membrane vesicle and conjugated Men A, C, W, Y-diphtheria toxoid carrier, for intramuscular use 90626 Tick-borne encephalitis virus vaccine, inactivated: 0.25 mL dosage, for intramuscular use
effective 7/1/2022 90627 Tick-borne encephalitis virus vaccine, inactivated: 0.5 mL dosage, for intramuscular use effective 7/1/2022 (deleted by CPT effective 1/1/2025)
90632 Hepatitis A vaccine (HepA), adult dosage, for intramuscular use 90633 Hepatitis A vaccine (HepA), pediatric/adolescent dosage-2 dose schedule, for intramuscular use 90634 Hepatitis A vaccine (HepA), pediatric/adolescent dosage-3 dose schedule, for intramuscular use 90635 Influenza virus vaccine, H5N1, (New Avian Flu vaccine) derived from cell cultures, adjuvanted, for
intramuscular use 90636 Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use
90644 Meningococcal conjugate vaccine, serogroups C & Y and Haemophilus influenzae type b

          vaccine (Hib-MenCY), 4 dose schedule, when administered to children 6 weeks-18 months of 
          age, for intramuscular use

90647 Haemophilus influenzae type b vaccine (Hib), PRP-OMP conjugate, 3 dose schedule,

         for intramuscular use

90648 Haemophilus influenzae type b vaccine (Hib), PRP-T conjugate, 4 dose schedule, for

          intramuscular use

90649 Human Papillomavirus vaccine, types 6, 11, 16, 18, quadrivalent (4vHPV), 3 dose schedule,

         for intramuscular use

90650 Human Papillomavirus vaccine, types 16, 18, bivalent (2vHPV), 3 dose schedule, for

          intramuscular use

90651 Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV),

         2 or 3 dose schedule, for intramuscular use

90653 Influenza vaccine, inactivated (IIV), subunit, adjuvanted, for intramuscular use (deleted by CPT effective 1/1/2025) 90655 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25 mL dosage,

         for intramuscular use

90656 Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 mL dosage,

         for intramuscular use

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 8 (401) 274-4848 WWW.BCBSRI.COM

90657 Influenza virus vaccine, trivalent (IIV3), split virus, 0.25 mL dosage, for intramuscular use
90658 Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for intramuscular use
90660 Influenza virus vaccine, trivalent, live (LAIV3), for intranasal use
90661 Influenza virus vaccine, trivalent (ccIIV3), derived from cell cultures, subunit, preservative

         and antibiotic free, 0.5 mL dosage, for intramuscular use

90662 Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via

          increased antigen content, for intramuscular use

90664 Influenza virus vaccine, live (LAIV), pandemic formulation, for intranasal use
90670 Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use 90671 Pneumococcal conjugate vaccine, 15 valent (PCV15), for intramuscular use 90672 Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use
90673 Influenza virus vaccine, trivalent (RIV3), derived from recombinant DNA, hemagglutinin

          (HA) protein only, preservative, and antibiotic free, for intramuscular use

90674 Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative

         and antibiotic free, 0.5 mL dosage, for intramuscular use

90675 Rabies vaccine, for intramuscular use
90676 Rabies vaccine, for intradermal use
90677 Pneumococcal conjugate vaccine, 20 valent (PCV20), for intramuscular use 90678 Respiratory syncytial virus (RSV) vaccine, preF, subunit, bivalent, for intramuscular use (Effective 10/1/2023) 90679 Respiratory syncytial virus vaccine, preF, recombinant, subunit, adjuvanted, for intramuscular use (Effective 10/1/2023) 90680 Rotavirus vaccine, pentavalent (RV5), 3 dose schedule, live, for oral use
90681 Rotavirus vaccine, human, attenuated (RV1), 2 dose schedule, live, for oral use
90682 Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA,

          hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use

90683 Respiratory syncytial virus vaccine, mRNA lipid nanoparticles, for intramuscular use
90685 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL dosage,

         for intramuscular use

90686 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage,

         for intramuscular use

90687 Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25 mL dosage, for intramuscular use
90688 Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 mL dosage, for intramuscular use
90689 Influenza virus vaccine quadrivalent (IIV4), inactivated, adjuvanted, preservative free,

          0.25 mL dosage, for intramuscular use

90694 Influenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, preservative free, 0.5 mL

         dosage, for intramuscular use

90695 Influenza virus vaccine, H5N8, derived from cell cultures, adjuvanted, for intramuscular use

         (Avian bird flu)

90696 Diphtheria, tetanus toxoids, acellular pertussis vaccine and inactivated poliovirus vaccine

         (DTaP-IPV), when administered to children 4 through 6 years of age, for intramuscular use

90697 Diphtheria, tetanus toxoids, acellular pertussis vaccine,

          inactivated poliovirus vaccine, Haemophilus influenzae type b PRP-OMP conjugate vaccine,  
          and hepatitis B vaccine (DTaPIPV-Hib-HepB), for intramuscular use

90698 Diphtheria, tetanus toxoids, acellular pertussis vaccine, Haemophilus influenzae type b,

          and inactivated poliovirus vaccine (DTaP-IPV/Hib), for intramuscular use

90700 Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), for use in individuals

          younger than 7 years, for intramuscular

90702 Diphtheria and tetanus toxoids adsorbed (DT) when administered to individuals younger

          than 7 years, for intramuscular use

90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use
90710 Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use
90713 Poliovirus vaccine, inactivated, (IPV), for subcutaneous or intramuscular use
90714 Tetanus and diphtheria toxoids adsorbed (Td), preservative free, when administered to individuals

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 9 (401) 274-4848 WWW.BCBSRI.COM

         7 years or older, for intramuscular use

90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine (TdaP), for use in individuals 7 years

         or older, for intramuscular use

90716 Varicella virus vaccine (VAR), live, for subcutaneous use
90723 Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus

         vaccine, inactivated (DtaP-HepB-IPV), for

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

90733 Meningococcal polysaccharide vaccine, serogroups A, C, Y, W-135, quadrivalent (MPSV4),

         for subcutaneous use

90734 Meningococcal conjugate vaccine, serogroups A, C, Y and W-135, quadrivalent (MCV4

         or MenACWY), for intramuscular use

90736 Zoster (shingles) vaccine (HZV), live, for subcutaneous injection (age 50 years of age and above) 90739 Hepatitis B vaccine (HepB), adult dosage, 2 dose schedule, for intramuscular use
90740 Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 3 dose schedule,

         for intramuscular use

90743 Hepatitis B vaccine (HepB), adolescent, 2 dose schedule, for intramuscular use 90744 Hepatitis B vaccine (HepB), pediatric/adolescent dosage, 3 dose schedule, for intramuscular use
90746 Hepatitis B vaccine (HepB), adult dosage, 3 dose schedule, for intramuscular use
90747 Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 4 dose schedule,

         for intramuscular use

90748 Hepatitis B and Haemophilus influenzae type b vaccine (Hib-HepB), for intramuscular use
90750 Zoster (shingles) vaccine (HZV), recombinant, sub-unit, adjuvanted, for intramuscular injection

          (age 50 years of age and above includes the 2 dose vaccine)

90756 Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic

          free, 0.5mL dosage, for intramuscular use

90759 Hepatitis B vaccine (HepB), 3-antigen (S, Pre-S1, Pre-S2), 10 mcg dosage, 3 dose schedule, for I

intramuscular use effective 7/1/2022 90758 Zaire ebolavirus vaccine, live, for intramuscular use (Effective 7/1/2021) 91318 Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, 3 mcg/0.2 mL dosage, tris-sucrose formulation, for intramuscular use 91319 Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, 10 mcg/0.2 mL dosage, tris-sucrose formulation, for intramuscular use 91320 Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, 30 mcg/0.3 mL dosage, tris-sucrose formulation, for intramuscular use 91321 Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, 25 mcg/0.25 mL dosage, for intramuscular use 91322 Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, 50 mcg/0.5 mL dosage, for intramuscular use 91323 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, 10 mcg/0.2 mL dosage, for intramuscular use Q2034 Influenza virus vaccine, split virus, for intramuscular use (Agriflu) Q2035 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older,

           for intramuscular use (Afluria)

Q2036 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older,

          for intramuscular use (Flulaval)

Q2037 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older,

          for intramuscular use (Fluvirin)

Q2038 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older,

          for intramuscular use (Fluzone)

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 10 (401) 274-4848 WWW.BCBSRI.COM

The following CPT immunization codes are non-covered/contract exclusions as applicable for Medicare Advantage Plans and Commercial products as they are pending FDA approval: 90666 Influenza virus vaccine (IIV), pandemic formulation, split virus, preservative free,

          for intramuscular use

90667 Influenza virus vaccine (IIV), pandemic formulation, split virus, adjuvanted, for

          intramuscular use

90668 Influenza virus vaccine (IIV), pandemic formulation, split virus, for intramuscular use

The following CPT vaccine travel codes are covered for Commercial products:

90625 Cholera vaccine, live, adult dosage, 1 dose schedule, for oral use
90690 Typhoid vaccine, live, oral 90691 Typhoid vaccine, Vi capsular polysaccharide (ViCPs), for intramuscular use 90717 Yellow fever vaccine, live, for subcutaneous use 90738 Japanese encephalitis virus vaccine, inactivated, for intramuscular use
90589 Chikungunya virus vaccine, live attenuated, for intramuscular use

The following CPT codes for individual and group counseling are non-covered when used for travel immunization counseling for Medicare Advantage Plans and Commercial products:

99401 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to

         an individual (separate procedure); approximately 15 minutes

99402 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to

         an individual (separate procedure); approximately 30 minutes

99403 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to

         an individual (separate procedure); approximately 45 minutes

99404 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to

         an individual (separate procedure); approximately 60 minutes

99411 Preventive medicine counseling and/or risk factor reduction intervention(s) provided

         to individuals in a group setting (separate procedure); approximately 30 minutes

99412 Preventive medicine counseling and/or risk factor reduction intervention(s) provided

         to individuals in a group setting (separate procedure); approximately 60 minutes

The following HCPCS codes are separately reimbursed for Medicare Advantage Plans Please Note: Also refer to the separate policy for Preventive Services for Medicare Advantage Plans for correct coding.
G0008 Administration of influenza virus vaccine G0009 Administration of pneumococcal vaccine G0010 Administration of hepatitis B vaccine

For the following codes for Medicare Advantage Plans and Commercial products, please follow the unlisted procedures process: 90749 Unlisted vaccine/toxoid Q2039 Influenza virus vaccine, not otherwise specified

RELATED POLICIES Preventive Services for Commercial
Preventive Services for Medicare Advantage Plans Advance Notice of Non-Coverage
Unlisted Procedures Rabies Treatment: Pre and Post Exposure

PUBLISHED Provider Update, January 2025 Provider Update, July 2024

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 11 (401) 274-4848 WWW.BCBSRI.COM

Provider Update, January 2024 Provider Update, November 2023 Provider Update, July 2023 Provider Update, February 2023 Provider Update, November 2022 Provider Update, September 2022 Provider Update, July 2021 Provider Update, August 2020 Provider Update, May 2019 Provider Update, April 2018 Provider Update, March 2017

REFERENCES:

1. CDC Centers for Disease Control and Prevention Vaccine Recommendations Advisory Committee for Immunization Practices (ACIP): http://www.cdc.gov/vaccines/hcp/acip-recs/index.html
2. American Academy of Pediatrics (AAP) Immunizations: http://www2.aap.org/immunization/
3. State of Rhode Island Department of Health Immunization, Office of: http://www.health.ri.gov/programs/immunization/
4. Department of Health and Human Services Centers for Medicare & Medicaid Services Medicare Learning Network MLN Matters 2014-2015 Influenza (Flu) Resources for Health Care Professionals:
   https://www.cms.gov/outreach-and-education/medicare-learning-network- mln/mlnmattersarticles/downloads/se1431.pdf
5. Department of Health and Human Services Centers for Medicare & Medicaid Services MLN Matters® Number: SE1523 2015-2016 Influenza (Flu) Resources for Health Care Professionals
   https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/SE1523.pdf
6. CMS.gov Centers for Medicare and Medicaid Services Immunizations: http://www.cms.gov/Medicare/Prevention/Immunizations/index.html?redirect=/immunization
7. Department of Health and Human Services Centers for Medicare and Medicaid Services Medicare Learning Network Modifications to Medicare Part B Coverage of Pneumococcal Vaccinations
   https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/MM9051.pdf
8. TITLE 27 Insurance CHAPTER 27-38.1 Insurance Coverage for Pediatric Preventive Care
   Section 27-38.1-2 Coverage required for pediatric preventive care
9. U. S. Food and Drug Administration. Vaccines, Blood and Biologicals. Complete list of vaccines licensed
   for immunization and distribution in the US. http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM093833
10. CMS.gov Article - Billing and Coding: Immunizations (A56900) (cms.gov)
    CPT Code 90636
11. AMA announces CPT update for monkeypox testing and vaccination https://www.ama-assn.org/press- center/press-releases/ama-announces-cpt-update-monkeypox-testing-and-vaccination
12. FDA Authorizes Changes to Simplify Use of Bivalent mRNA COVID-19 vaccines https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes- changes-simplify-use-bivalent-mrna-covid-19-vaccines
13. http://webserver.rilin.state.ri.us/Statutes/TITLE27/27-18/27-18-86.htm
14. https://www.ama-assn.org/practice-management/cpt/covid-19-cpt-vaccine-and-immunization-codes
15. Use of Nirsevimab for the Prevention of Respiratory Syncytial Virus Disease Among Infants and Young Children: Recommendations of the Advisory Committee on Immunization Practice https://www.cdc.gov/mmwr/volumes/72/wr/mm7234a4.htm

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 12 (401) 274-4848 WWW.BCBSRI.COM

16. Use of Respiratory Syncytial Virus Vaccines in Older Adults: Recommendations of the Advisory Committee on Immunization Practices https://www.cdc.gov/mmwr/volumes/72/wr/mm7229a4.htm

17. https://www.ama-assn.org/system/files/vaccine-long-descriptors.pdf

    i

    This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.

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