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.
- 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.
| 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 |
| 90611 |
Smallpox and monkeypox vaccine, attenuated vaccinia virus, live, non-replicating, preservative free, 0.5 mL dosage, suspension, for subcutaneous use |
YES | YES (adults) VFC (children) |
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) VFC (children) |
NO |
| 90621 |
Meningococcal recombinant lipoprotein vaccine, Serogroup B (MenB-FHbp), 2 or 3 dose schedule, for intramuscular use |
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 |
| 90630 | Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use BN: No product available |
N/A | N/A | N/A |
| 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 |
| 90654 | Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, for intradermal use. 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 |
YES | YES (adults) VFC (children) |
YES |
| 90657 | Influenza virus vaccine, trivalent (IIV3), split virus, for intramuscular use BN: AFLURIA, FLUZONE |
YES |
YES (adults) |
YES |
| 90658 |
Influenza virus vaccine, trivalent (IIV3), split virus, 0.5ml dose, for intramuscular use |
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 (ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, 0.5ml dose 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) |
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) 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) |
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 |
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 |
| 90678 | 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 |
YES | YES | NO |
| 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 |
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 |
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 |
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 |
YES | YES (adults) VFC (children) |
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 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 |
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) Ages: 12 years & up |
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) 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) |
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