Influenza vaccine coverage
- Self-funded plan coverage will vary by employer group, depending on purchase of coverage for general immunizations, flu shots and pharmacy benefits. Self-funded plans may also place additional restrictions on member use of out-of-network providers.
- Coinsurance and out-of-network benefits may apply. Reference plan documents for details.
- Vaccine shortages: In the event of a vaccine shortage, Priority Health will issue written guidelines and post them on this website. Note: A shortage is not the same as a delay from your vendor.
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Flu vaccine coverage by plan, effective 09/01/2024
Child = 0-18 years Adult = 19 + years
| Codes | Description | HMO/EPO, POS, PPO |
Medicaid & Healthy Michigan Plan | Medicare Advantage plans |
|---|---|---|---|---|
| 90630 |
Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use |
N/A | N/A | N/A |
| 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 |
| 90653 | Influenza virus vaccine, inactivated (IIV), subunit, adjuvanted, for intramuscular use BN: FLUAD |
Covered | Adults: Covered Children: VFC |
Covered |
| 90654 | Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, for intradermal use BN: No active NDC for this code |
N/A | N/A | N/A |
| 90655 | Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25mL dosage, for intramuscular use BN: No active NDC for this code |
N/A | N/A | N/A |
| 90656 |
Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, for 0.5mL dosage, for intramuscular use Ages: 6 months and older BN: AFLURIA, FLUZONE, FLUVARIX, FLULAVAL |
Covered | Adults: Covered Children: VFC |
Covered |
| 90657 | Influenza virus vaccine, trivalent (IIV3), split virus, 0.25mL dosage, for intramuscular use Ages: 6 months and older BN: AFLURIA, FLUZONE |
Covered | Adults: Covered Children: VFC |
Covered |
| 90658 |
Influenza virus vaccine, trivalent (IIV3), split virus, 0.5mL dosage, for intramuscular use Ages: 6 months and older BN: AFLURIA, FLUZONE |
Covered | Adults: Covered Children: VFC |
Covered |
| 90660 | Influenza virus vaccine, trivalent (LAIV3), live, for intranasal use Ages: 2-49 years BN:FLUMIST |
Covered | Adults: Covered Children: VFC |
Covered |
| 90661 | Influenza virus vaccine (ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, 0.5mL dosage, for intramuscular use Ages: 6 months and older BN: FLUCELVAX |
Covered | Adults: Covered Children: VFC |
Covered |
| 90662 | Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use Ages 65 years & older only BN: FLUZONE HIGH DOSE |
Covered | Covered | Covered |
| 90664 | Influenza virus vaccine, live (LAIV) pandemic formulation, for intranasal use BN: No active NDC for this code |
N/A | N/A | N/A |
| 90666 |
Influenza virus vaccine (IIV), pandemic formulation, split virus, preservative free, for intramuscular use BN: No active NDC for this code |
N/A | N/A | N/A |
| 90667 |
Influenza virus vaccine (IIV), pandemic formulation, split virus, adjuvanted, for intramuscular use BN: No active NDC for this code |
N/A | N/A | N/A |
| 90668 |
Influenza virus vaccine (IIV), pandemic formulation, split virus, for intramuscular use BN: No active NDC for this code |
N/A | N/A | N/A |
| 90672 | Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use BN: No active NCD for this code |
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 |
Covered | Adults: Covered Children: VFC |
Covered |
| 90674 | Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use BN: No active NDC for this code |
N/A | N/A | N/A |
| 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 |
| 90685 |
Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL dosage, for intramuscular use |
N/A | N/A | N/A |
| 90686 | Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5mL dosage, for intramuscular use BN: No active NDC for this code |
N/A | N/A | N/A |
| 90687 | Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25mL dosage, for intramuscular use BN: No active NDC for this code |
N/A | N/A | N/A |
| 90688 |
Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5mL dosage, 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 BN: No active NDC for this code |
N/A | N/A | N/A |
| 90694 | Influenza virus vaccine, quadrivalent (allV4), inactivated, adjuvanted, preservative free, 0.5 mL dosage, for intramuscular use BN: No active NDC for this code |
N/A | N/A | N/A |
| 90695 |
Influenza virus vaccine, H5N8, derived from cell cultures, adjuvanted, for intramuscular use Awaiting FDA approval |
N/A | N/A | N/A |
| 90749 | Unlisted Vaccine/Toxoid BN: FLUCELVAX |
Covered | Adults: Covered Children: VFC |
Covered |
| 90756 | Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5mL dosage, for intramuscular use BN: No active NDC for this code |
N/A | N/A | N/A |
| Q2034 | Influenza virus vaccine, split virus, for intramuscular use (AGRIFLU) BN: No active NDC for this code |
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 |
Covered | Adults: Covered Children: VFC |
Covered |
| Q2036 | Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use (FLULAVAL) BN: No active NDC for this code |
N/A | N/A | N/A |
| Q2037 | Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use (FLUVARIN) BN: No active NDC for this code |
N/A | N/A |
N/A |
| Q2038 | Influenza virus vaccine, split virus, for use in individuals 3 years of age and older, for intramuscular use BN: FLUZONE |
Covered | Adults: Covered Children: VFC |
Covered |
| Q2039 | Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified) BN: FLUCELVAX |
Covered | Adults: Covered Children: VFC |
Covered |
Flu vaccine administration coverage by plan
| Administration codes | Description | HMO/EPO, POS, PPO |
Medicaid & Healthy Michigan Plan | Medicare Advantage | |
|---|---|---|---|---|---|
| 90460 90461 90471 90472 90473 90474 |
CPT codes for vaccine administration. (See description to select the most appropriate code) | Covered1 | Covered1 |
Not covered1 See G codes |
|
| 1 Office copay usually does not apply if vaccine administration is the only service rendered. | |||||
| G0008 | HCPCS code for seasonal flu vaccine administration for Medicare patients | Not covered2 | Not covered2 |
Covered |
|
| 2 Office copay usually does not apply if vaccine administration is the only service rendered. | |||||
Seasonal flu vaccine coverage by location
| Location |
HMO or EPO |
POS
Preferred benefit for in-network providers Alternate benefit for out-of-network providers |
PPO
In-network benefit for in-network providers Out-of-network benefit for out-of-network providers |
Medicaid & Healthy Michigan Plan | Medicare Advantage |
|
|---|---|---|---|---|---|---|
| Physician office | Covered at in-network providers | Covered | Covered |
Covered VFC restrictions apply |
Covered |
|
| Community clinics | Covered at in-network providers | Covered | Covered |
Covered VFC restrictions apply |
Covered |
|
| In-network providers must bill us directly. Member cannot file a claim form for reimbursement. Commercial plans: Out-of-network providers may bill us or member can pay and file for reimbursement. Coverage is subject to out-of-network benefits. Priority Health Medicare Advantage plan members: Cost is $0 in any out-of-network setting. Non-contracted providers should bill Priority Health. Coverage is subject to out-of-network benefits. |
||||||
| Home health care services | Covered if the health care organization contracts with us and bills us directly. The cost for administration is included in the cost of the nursing visit. | |||||
| Health departments | Covered at in-network providers | Covered | Covered | Covered
No member reimbursement; provider must bill VFC restrictions apply |
Covered | |
| In-network providers must bill us directly. Member cannot file a claim form for reimbursement. Commercial plans: Out-of-network providers may bill us or member can pay and file for reimbursement. Coverage is subject to out-of-network benefits. Priority Health Medicare Advantage members: Cost is $0 in any out-of-network setting. Non-contracted providers should bill Priority Health. |
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| Pharmacies that participate in the Express Scripts network | Covered3 | Covered3 | Covered3 | Covered for members age 19 and over | Covered | |
|
3 Commercial member must have prescription coverage. Pharmacy will bill us directly. |
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| Urgent care centers | Covered at in-network-providers | Covered | Covered | Covered
VFC restrictions apply |
Covered | |
| If the center contracts with Priority Health, it must bill us directly. Member cannot file a claim form for reimbursement. Commercial plans: Out-of-network providers may bill us or member can pay and file for reimbursement. Subject to out-of-network benefits. Priority Health Medicare Advantage members: Cost is $0 in any out-of-network setting. Non-contracted providers should bill Priority Health. Urgent care copay will not apply if only service is flu vaccine. |
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| Work site flu clinic | Covered | Covered | Covered | Not applicable | Not applicable | |
| Covered if the provider contracts with Priority Health and bills us directly; member cannot file for reimbursement. Not covered if the employer has a discount arrangement with the provider (even if contracted) and the provider will be paid directly by the employer. Member cannot file a claim form for reimbursement. |
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Preventive care:
- Preventive service codes
- Vaccine codes
- Vaccine administration
- Flu vaccines
- Lung cancer CT screenings
- Pelvic & breast exams, Pap tests
- Prenatal & maternity care
- Long-acting reversible contraceptives, Medicaid
- Well-child visits
- Medicare preventive services
Vaccines coding key
- VFC = Vaccines for Children program. For Medicaid beneficiaries aged 0-18 years, providers must obtain vaccines from the VFC program. Priority Health Choice will only reimburse the administration fee for vaccines obtained through the VFC program. Report both the vaccine ($0 charge) and administration on the claim.
- BN: Brand names, listed when available