Vaccine codes and coverage

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
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
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
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 (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)
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
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
Ages: 18 years & older
BN: CAPVAXIVE

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
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)