Commercial

Medical Policy

Notification

Routine/Non-routine Vaccines

Notification Issued Date:

This version of the policy will become effective XX/XX/2024.

The policy criteria were updated as follows:

Routine/Preventive vaccines

As previously communicated through a news article, the medically necessary criteria was updated for COVID-19 vaccine
Medically necessary criteria was updated for DTaP/Tdap/Td vaccines
Medically necessary criteria was updated for Hepatitis B vaccine
Medically necessary criteria was updated for measles, mumps, rubella, and varicella vaccines.
Medically necessary criteria was updated for meningococcal conjugate vaccines.
Medically necessary criteria was updated for pneumococcal vaccine.
Medically necessary criteria was updated for respiratory syncytial virus vaccine.
As previously communicated thoruhg a news article, the medically necessary criteria was added for smallpox and Mpox vaccine.
The not medically necesary criteira was removed for the SARS CoV-2 Wuhan-hu-1 monovalent COVID-19 vaccine.
PCV13 and MenACWY-D coverage positions have been updated to not eligible for reimbursement.
As previously communicated through a news article, experimental/investigational criteria was added for dengue vaccine.

Nonroutine/Nonpreventive Vaccines

The medically necessary criteria was removed from the section for the administration of Mpox and smallpox vaccine.
As previously communicated through a news article, the medically necessary criteria was removed from this section for PCV20 and PCV15 vaccines.
The medically necessary criteria was updated for RSV vaccine to add mRESVIA vaccine.
The not eligible for reimbursement criteria was removed for Mpox and smallpox vaccine.
As previously communicated through a news article, the medically necessary criteria was added for the administration of the MPox and smallpox vaccine

Title:

Routine/Non-routine Vaccines

Policy #:

08.01.04ag

Policy

State mandates do not automatically apply to all plans; therefore, individual benefits must be verified.

The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.

INDEX OF INDICATIONS

This policy addresses numerous routine/preventive and nonroutine/non-preventive indications for the use of vaccines listed in order of appearance within the Policy section. Please see below for the specific criteria.

Routine/Preventive Vaccines

Medically Necessary

COVID-19 Vaccine
Dengue Vaccine
DTaP/Tdap/Td Vaccines
Haemophilus Influenzae Type b (Hib) Vaccine
Hepatitis A Vaccine
Hepatitis B Vaccine
Human Papillomavirus Vaccine
Influenza Vaccine
Measles, Mumps, Rubella, and Varicella Vaccines
Meningococcal Conjugate Vaccines
Pneumococcal Vaccine
Polio Vaccine
Respiratory Syncytial Virus Vaccine
Rotavirus Vaccine
Smallpox and Mpox Vaccine
Zoster (Shingles) Vaccine
Combination Vaccines

Routine Vaccine Coverage During Outbreaks
Not eligible for reimbursement
Not eligible for separate reimbursement
Experimental/investigational

Dengue Vaccine
Respiratory Syncytial Virus Vaccine
Rotavirus Vaccine
Combination Vaccine
Zoster (Shingles) Vaccine
Human Papillomavirus Vaccine

Non-Routine/Non-Preventive Vaccines

Medically Necessary

BCG Vaccine
Pneumococcal Vaccine
Post-Exposure Rabies Vaccine
Preexposure Prophylaxis for Prevention of Anthrax Booster
Tdap/Td Vaccines
Typhoid Vaccine
Zoster (Shingles) Vaccine

Experimental/Investigational

Rabies Vaccine

Travel-related Vaccines
Employment/Occupational-related Vaccines

ROUTINE/PREVENTIVE VACCINES

MEDICALLY NECESSARY
In accordance with the Advisory Committee on Immunization Practices (ACIP), routine vaccines and their administration for the indications described below are covered as a preventive service.

COVID-19 Vaccine

The monovalent COVID-19 vaccine is considered medically necessary and, therefore, covered for the following indications:

Routine one to three-dose vaccination against COVID-19 for individuals ages 6 months and older
A COVID-19 booster vaccination for individuals ages 6 months and older.
An additional COVID-19 vaccination for individuals ages 65 years of age and older
An additional COVID-19 vaccination for individuals who are moderately or severely immunocompromised

Dengue Vaccine

The dengue vaccine, as a three-dose regimen, is considered medically necessary and, therefore, covered for individuals ages 9 to 16 years living in dengue-endemic areas and have laboratory confirmation of previous dengue infection.

DTaP/Tdap/Td Vaccines

The following vaccines against diphtheria, tetanus, and pertussis are considered medically necessary and, therefore, covered for nonimmune individuals at risk for diphtheria, tetanus, and pertussis:

Routine childhood diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccination regimen at ages 2 months, 4 months, 6 months, 15 months through 18 months, and 4 years through 6 years. A fourth dose given as early as age 12 months will be covered if at least 6 months have elapsed since the third dose.
Catch-up DTaP vaccination for under-vaccinated children under 7 years of age at subsequent visits.
Routine dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) for all adolescents aged 11 through 12 years.
Catch-up one-time dose of Tdap for under-vaccinated (i.e., missing DTaP doses) children ages 7 years through 10 years followed by a dose at age between 11 and 12 years.
Catch-up one-time dose of Tdap for adolescents ages 11 years through 18 years who have not received Tdap vaccine. This should be followed by tetanus and diphtheria (Td) booster doses every 10 years thereafter.
One-time dose of Tdap followed by one dose of Td every 10 years for adults ages 19 years and older who have not received tetanus, pertussis, and diphtheria toxoid containing vaccine.
One dose of Tdap to pregnant women during EACH pregnancy (preferred during 27–36 weeks gestation), regardless of the amount of time since prior Td or Tdap vaccination.
A Tdap booster vaccination for adolescents and adults any age (e.g., parents, siblings, grandparents) who previously have not received Tdap or whom pertussis vaccination status is unknown and who have, or anticipate having close contact with an infant less than 12 months of age.
A Td or Tdap booster vaccination once every 10 years for adults 19 years or older.

Haemophilus Influenzae Type b (Hib) Vaccine

Haemophilus influenzae type b (Hib) vaccine is considered medically necessary and, therefore, covered for the following individuals:

Routine childhood primary Hib vaccination series at ages 2 months, 4 months, and 6 months, and an Hib booster dose at ages 12 months through 15 months. (PRP-OMP is not indicated for the 6-month dose.)
Catch-up Hib vaccination for under-vaccinated children up to 5 years of age at subsequent visits.
Hib vaccination for children with specific health conditions (e.g., anatomic or functional asplenia [including sickle cell disease], hematopoietic stem cell transplantation, human immunodeficiency virus (HIV), immunoglobulin deficiency, early component complement deficiency, elective splenectomy, chemotherapy treatment, or radiation treatment).
Hib vaccination for adults with specific health conditions (i.e., anatomical or functional asplenia [including sickle cell disease], hematopoietic stem cell transplant, or undergoing splenectomy if they have not previously received Hib vaccine.)

Hepatitis A Vaccine

Hepatitis A virus (HAV) vaccine is considered medically necessary and, therefore, covered for the following individuals:

Routine two-dose regimen of hepatitis A (HepA) childhood vaccination. The first dose of HepA vaccine between 12 months and 23 months of age. Second (final) dose of HepA vaccine 6 to 18 months after the first.
Catch-up HepA vaccination for under-vaccinated children and adolescents up to 18 years of age at subsequent visits.
HAV vaccination for nonimmune individuals at risk for HAV infection (e.g., individuals with chronic liver disease (including but not limited to persons with hepatitis B virus (HBV) infection, hepatitis C virus (HCV) infection, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, or an alanine aminotransferase (ALT) or aspartate aminotransferase (AST) level persistently greater than twice the upper limit of normal), men who have sex with men, users of injection or noninjection illicit drugs, individuals with HIV infection, individuals living in nonresidential day care facilities, or homeless individuals).
Pregnant individuals who are identified to be at risk for hepatitis A infection during pregnancy (users of injection or noninjection drugs, individuals who anticipate close personal contact with an international adoptee, or homeless individuals, chronic liver disease, individuals with HIV infection).
Unvaccinated persons who anticipate close personal contact (household or babysitting) with an international adoptee during the first 60 days of their arrival from a country with high or intermediate endemicity
Adults who are not fully vaccinated and seeking protection from Hepatitis A.
HAV vaccination for individuals traveling to countries with high or intermediate endemicity.

Hepatitis B Vaccine

Hepatitis B virus (HBV) vaccine is considered medically necessary and, therefore, covered for the following individuals:

Pediatric

Routine childhood HBV vaccination within 24 hours of birth, ages 1 month through 2 months, and 6 months through 18 months. Monovalent HepB vaccine for doses before age 6 weeks.
Catch-up HBV vaccination for un-vaccinated children and adolescents through 18 years at subsequent visits.
Infants whose mother is HBsAg-positive or HBsAg status is unknown regardless of birth weight are covered for one dose of monovalent HepB vaccine within 12 hours of birth.
Medically stable infants weighing at least 2,000 grams whose mothers are HBsAg-negative are covered for one dose of monovalent HepB vaccine within 24 hours of birth.
Infants weighing less than 2,000 grams whose mothers are HBsAg-negative are covered for one dose of monovalent HepB vaccine at chronological age 1 month or hospital discharge.

Adults

Routine HBV vaccination for individuals, ages 19 years through 59 years.
Non-immune individuals ages 60 years or older without known risk factors for Hepatitis B infection seeking protection from HBV infection.
Individuals ages 60 years or older at risk for Hepatitis B infection, including, but not limited to:

Diagnosed with diabetes mellitus

Sexually active individuals who are not in a long-term mutually monogamous relationship
Individuals seeking evaluation or treatment for a sexually transmitted disease
Current or recent injection drug users
Men who have sex with men
Individuals with end-stage renal disease including those who are receiving pre-dialysis care, hemodialysis, peritoneal dialysis, or home dialysis
Individuals with HIV infection
Individuals with chronic liver disease (e.g., hepatitis C infection, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, alanine aminotransferase [ALT] or aspartate aminotransferase [AST] level greater than twice the upper limit of normal)
Household contacts and sex partners of hepatitis B surface antigen--positive individuals
Individuals receiving care in settings where a high proportion of adults have risks for hepatitis B infection.
International travelers to countries with high or intermediate levels of endemic HBV infection (HBsAg prevalence is 2% or greater)

Human Papillomavirus Vaccine

9-valent papillomavirus vaccine (9vHPV) is considered medically necessary and, therefore, covered for the following individuals:

Routine two-dose regimen of 9vHPV for individuals 11 years or 12 years of age administered 6 to 12 months after the first dose. The vaccination series is covered beginning at 9 years.
Catch-up HPV vaccination for individuals through 26 years of age who are not adequately vaccinated. Individuals who begin vaccination ages 9 through 14 years are covered for the two-dose regimen of 9vHPV vaccine. Individuals who begin the vaccination series at age 15 years through 45 years are covered for the three-dose regimen of 9vHPV vaccine.
Vaccination when indicated by shared clinical decision-making for individuals 27 years through 45 years who are not adequately vaccinated.
HPV vaccines are not recommended for use during pregnancy.

Influenza Vaccine

Influenza vaccine is considered medically necessary and, therefore, covered for the following individuals:

Two-dose regimen for individuals age 6 months through 8 years receiving their first-time influenza vaccination or who have not previously received two or more doses of trivalent or quadrivalent vaccine before July 1, 2023.
Annual influenza vaccination for individuals from age 6 months and older with annual influenza vaccination with recombinant influenza vaccine (RIV), inactivated influenza vaccine (IIV), or live attenuated influenza vaccine (LAIV). LAIV is covered for individuals 2 years or older. RIV is covered for individuals 18 years or older.
Annual influenza vaccination with a standard-dose IIV for adults age 65 years and older or, alternatively, RIV or a high-dose of IIV.

Measles, Mumps, Rubella, and Varicella Vaccines

Measles, mumps, rubella vaccine (MMR) and varicella vaccine or combination measles, mumps, rubella, and varicella vaccine (MMRV) is considered medically necessary and, therefore, covered for the following individuals:

Routine childhood vaccination against measles, mumps, rubella, and varicella at ages 12 months through 15 months, and at ages 4 years through 6 years. The second dose may be covered before 4 years of age.
Catch-up measles, mumps, rubella, and varicella vaccination for under-vaccinated or unvaccinated children and adolescents up to 12 years of age at subsequent visits.
A mumps-containing vaccine for individuals who were previously vaccinated with a two dose of mumps-virus containing vaccine who are identified by the public health authorities to be at increased risk during a mumps outbreak.
A two-dose regimen of MMR vaccination for nonimmune adults at risk for measles and mumps infection (e.g., students in post-secondary educational institutions and household contacts of immunocompromised individuals).
One dose of MMR vaccination for individuals who lack evidence of measles, mumps, or rubella immunity.
A two-dose regimen of single-antigen varicella vaccination for unvaccinated adults who lack evidence of varicella immunity.
MMR vaccine and varicella vaccine are covered for females of childbearing age and females after pregnancy before discharge with no evidence of immunity.
MMR vaccination before departure for international travel.

Meningococcal Conjugate Vaccines

Meningococcal conjugate vaccine (MenACWY-CRM, MenABCWY, MenACWY-TT, MenACWY-TT/MenB-FHbp) ) is considered medically necessary and, therefore, covered for the following individuals:

Routine two-dose regimen of meningococcal vaccination (MenACWY-CRM, MenACWY-TT, or MenACWY-TT/MenB-FHbp) for adolescents age 11 years or 12 years, and at age 16 years.
A catch-up dose at age 13 through 18 years if not previously vaccinated.
For individuals aged 2 months or older with high risk conditions or at increased risk of disease (i.e., anatomic or functional asplenia [including sickle cell disease], HIV infection, persistent complement component deficiency [individuals with inherited or chronic deficiency in C3, C5-9, properdin, factor D, factor H, or taking eculizumab [Soliris®] or ravulizumab [Ultomiris ®]) with MenACWY-TT or MenACWY-CRM.
For adults at risk of a meningococcal disease outbreak attributed to serogroup A, C, W, or Y.
First-year college students who are living in residence halls are covered if not previously vaccinated at 16 years or older or are military recruits.
Revaccination with MenACWY-CRM every 5 years is covered for adults previously vaccinated with MenACWY-CRM who remain at increased risk for infection (e.g., adults with anatomic or functional asplenia, persistent complement component deficiencies).
Individuals who travel to countries where meningococcal disease is hyperendemic or epidemic, including countries in the African meningitis belt or during the Hajj.
Vaccination when indicated by shared clinical decision-making for individuals 16 years through 23 years (preferred age 16–18 years) not at increased risk for meningococcal disease.

Serogroup B meningococcal (MenB) vaccine is considered medically necessary and, therefore, covered for the following:

Two-dose series or three dose series to individuals 10 years or older who are at increased risk for meningococcal disease with any of the following:

Persistent complement component deficiencies (including inherited or chronic deficiencies in C3, C5-9, properdin, factor D, factor H, or who are taking eculizumab [Soliris®] or ravulizumab [Ultomiris ®])
Anatomic or functional asplenia including sickle cell disease
Identified at increased risk because of a serogroup B meningococcal disease outbreak

Individuals 16 through 23 years (preferred age 16–18 years) are covered when vaccinated with a 2-dose series or a 3-dose series to provide short-term protection against most strains of serogroup B meningococcal disease. The same product must be used for all doses.
A booster vaccine for the following individuals:

Individuals at increased risk, a MenB booster dose 1 year following completion of a MenB primary series followed by MenB booster doses every 2-3 years thereafter, for as long as increased risk remains.
Individuals aged 10 years or older determined by public health officials to be at increased risk during an outbreak

Pneumococcal Vaccine

15-valent pneumococcal conjugate vaccine (PCV15), 20-valent pneumococcal conjugate vaccine (PCV20), 21- valent Pneumococcal conjugate vaccine, or 23-valent pneumococcal polysaccharide vaccine (PPSV23), are considered medically necessary and, therefore, covered for the following individuals:

Pediatric

Routine childhood PCV15 or PCV20 vaccination at ages 2 months, 4 months, 6 months, and 12 months through 15 months. The first dose of PCV15 or PCV20 are covered as early as 6 weeks of age.
Catch-up PCV15 or PCV20 vaccination for under-vaccinated healthy children up to 5 years of age at subsequent visits.
Vaccination of persons with high-risk conditions with PCV15, PCV20, or PPSV23:

For children 2 years through 18 years of age with any of the following conditions: chronic heart disease (particularly cyanotic congenital heart disease and cardiac failure); chronic lung disease (including asthma if treated with high-dose corticosteroid therapy); diabetes mellitus; cerebrospinal fluid leak; cochlear implant; sickle cell disease and other hemoglobinopathies; anatomic or functional asplenia; HIV infection; chronic renal failure; nephrotic syndrome; diseases associated with immunosuppressive drugs or radiation therapy, including malignant neoplasms, leukemias, lymphomas, and Hodgkin disease; solid organ transplantation; acquired or congenital immunodeficiency; multiple myeloma.

Adults 19 years and older

Adults aged 19 years through 64 years with certain underlying chronic medical conditions or risk factors who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown

(e.g. chronic heart disease chronic lung disease (e.g. asthma, COPD, emphysema), chronic liver disease, diabetes mellitus, alcoholism, chronic renal failure, cochlear implant, congenital or acquired asplenia, cerebrospinal fluid leak, generalized malignancy, HIV, Hodgkin disease, immunodeficiency, iatrogenic immunosuppression, leukemia, lymphoma, multiple myeloma, nephrotic syndrome, solid organ transplants, sickle cell disease, other hemoglobinopathies or who smokes cigarettes.

Individuals 65 years or older who have not previously received a pneumococcal vaccine or whose previous vaccination history is unknown
PCV21 as an alternative for individuals 19 years and older who currently have a recommendation to receive a dose of PCV.

Polio Vaccine

Inactivated poliovirus vaccine (IPV) is considered medically necessary and, therefore, covered for the following individuals:

Routine childhood polio vaccination at ages 2 months, 4 months, 6 months through 18 months, and 4 years through 6 years.
Catch-up polio vaccination for under-vaccinated children and adolescents up to 18 years at subsequent visits.
Polio vaccination for certain high-risk groups (e.g., unvaccinated adults with children receiving oral poliovirus vaccine [OPV], members of specific populations at risk for wild poliovirus infections, or individuals that travel to areas or countries where polio is epidemic or endemic).

Respiratory Syncytial Virus Vaccine

Pediatric

Respiratory syncytial virus (RSV) immunization (i.e., nirsevimab-alip [Beyfortus]) is considered medically necessary and, therefore, covered for the following individuals:

For all infants under 8 months regardless of risk who are born during the current RSV season or entering their first RSV season as a one-dose regimen.

The recommended dosage of nirsevimab-alip (Beyfortus) for neonates and infants born during or entering their first RSV season is based on body weight and is administered as a single intramuscular (IM) injection.
In accordance with the American Academy of Pediatrics (AAP), nirsevimab-alip (Beyfortus) administration is recommended to occur in the first week of life for infants born shortly before and during the RSV season based on geography. Administration of nirsevimab-alip (Beyfortus) may occur during the birth hospitalization or in an outpatient setting.

For children ages 8 to 19 months who are entering their second RSV season and who are at increased risk of severe RSV, including those who are eligible for palivizumab (Synagis) as a two-dose regimen.

Increased risk factors include, but are not limited to:

Chronic lung disease of prematurity (defined by the AAP as an individual with a gestational age less than 32 weeks, 0 days, who required more than 21% oxygen for at least the first 28 days after birth) requiring medical support (i.e., chronic corticosteroid therapy, diuretic therapy, or supplemental oxygen) any time during the 6-month period before the start of the second RSV season
Hemodynamically significant congenital heart disease
Severe immunocompromise
Cystic fibrosis with severe lung disease (defined as having a previous hospitalization for pulmonary exacerbation in the first year of life or abnormalities on chest imaging that persist when stable ) or weight-for-length less than the 10th percentile
American Indian and Alaska Native children

Note: In accordance with AAP, if nirsevimab-alip (Beyfortus) is administered, palivizumab (Synagis) should not be administered later that season. If palivizumab (Synagis) was administered initially for the season and less than five doses were administered, the infant should receive one dose of nirsevimab-alip (Beyfortus) and no further palivizumab (Synagis) should be administered. If palivizumab (Synagis) was administered in the first season and the child is eligible for RSV prophylaxis in the second season, the child should receive nirsevimab-alip (Beyfortus) in the second season, if available. If nirsevimab-alip is not available, palivizumab (Synagis) should be administered as previously recommended.

Note: In accordance with the Centers for Disease Control and Prevention (CDC), most infants will likely only need protection from either the maternal RSV vaccine or infant immunization, but not both. However, for example, if an infant is born less than 2 weeks after maternal immunization, then a provider may recommend that the infant also receive the infant immunization.

Adults

RSV vaccine (i.e., respiratory syncytial virus vaccine, adjuvanted [Arexvy] or respiratory syncytial virus vaccine [Abrysvo or mRESVIA] ) is considered medically necessary and, therefore, covered as a one-time dose regimen for the following individuals:

Individuals 60 to 74 years of age who are at increased risk of severe RSV disease.

Increased risk factors include, but are not limited to:

Chronic cardiovascular disease (e.g., heart failure, coronary artery disease, or congential heart disease [excluding isolated hypertension])
Chronic lung disease (e.g.' chronic obstructive pulmonary disease, emphysema, asthma, interstitial lung disease, or cystitic fibrosis)
End-stage renal disease or dependence on hemodialysis or other renal replacement therapy
Diabetes mellitus complicated by chronic kidney disease, neuropathy, retinopathy, or other end-organ damage, or requiring treatment with insulin or sodium-glucose cotransporter-2 (SGLT2) inhibitor
Neurologic or neuromuscular conditions causing impaired airway clearance or respiratory muscle weakness (e.g., poststroke dysphagia, amyotrophic lateral sclerosis, or muscular dystrophy [excluding history of stroke without impaired airway clearance])
Chronic liver disease (e.g., cirrhosis)
Chronic hematologic conditions (e.g., sickle cell disease or thalassemia)
Severe obesity (body mass index 40kg/m2 or greater)
Moderate or severe immune compromise
Residence in a hursing home
Other chronic medical conditions or risk factors that a professional provider determines would increase the risk for severe disease due to viral respiratory infection

Individuals 75 years of age and older.

RSV vaccine (i.e., respiratory syncytial virus vaccine [Abrysvo]) is considered medically necessary and, therefore, covered as a one-time dose for pregnant individuals at 32 through 36 weeks gestational age.

Billing Requirements

When reporting the RSV vaccine (i.e., respiratory syncytial virus vaccine [Abrysvo]) for a pregnant individual, a maternity diagnosis code must be reported on the claim.

Rotavirus Vaccine

Rotavirus vaccines (RV5 [RotaTeq] or RV1 [Rotarix]) are considered medically necessary and, therefore, covered for the following individuals:

An oral three-dose live, human-bovine pentavalent rotavirus vaccination (RV5) regimen at ages 2 months, 4 months, and 6 months.
An oral two-dose live, human-attenuated rotavirus vaccination (RV1) regimen at ages 2 months and 4 months.
A total of up to three doses of rotavirus vaccines if prior vaccination included use of RotaTeq (RV5) or unknown rotavirus vaccines.
Catch-up rotavirus vaccination up to 8 months of age.

Smallpox and Mpox Vaccine

Smallpox and mpox vaccine, live, non-replicating (Jynneos) vaccine is considered medically necessary and, therefore, covered as a two-dose vaccine for individuals 18 years and older who are at risk for Mpox.

According to ACIP, risk factors for Mpox are:

Gay, bisexual, and other men who have sex with men, transgender or nonbinary individuals who in the past six months had one of the following:

A new diagnosis of at least one sexually transmitted disease
More than one sex partner
Sex at a commercial sex venue
Sex in association with a large public event in a geographic area where mpox transmission is occurring.

Sexual partners of individuals with the aforementioned risk factors
Individuals who anticipate experiencing any of the aforementioned risk factors

Zoster (Shingles) Vaccine

Zoster (shingles) vaccine is considered medically necessary and, therefore, covered for the following individuals:

Recombinant zoster vaccine for immunocompetent individuals age 50 years or older, regardless of whether they experienced a prior episode of herpes zoster or received zoster vaccine live.
Individuals 19 years or older who are or will be immunodeficient or immunosuppressed due to disease or therapy.

Combination Vaccines

Vaxelis™, diphtheria and tetanus toxoids and acellular pertussis vaccine adsorbed, inactivated poliovirus, Hemophilus b conjugate and Hepatitis B vaccine (DTaP-IPV-Hib-HepB), is considered medically necessary and, therefore, covered for individuals ages 6 weeks through 4 years of age.

ROUTINE VACCINE COVERAGE DURING OUTBREAKS

In accordance with vaccine specific immunization recommendations from the US Centers for Disease Control and Prevention (CDC), routine vaccines are covered for individuals who are identified by the public health authorities to be at increased risk during an outbreak.

NOT ELIGIBLE FOR REIMBURSEMENT

The following vaccines are no longer manufactured and have been withdrawn from the market, therefore, they are not eligible for reimbursement:

Hepatitis A vaccine, 3-dose schedule intramuscular
Bivalent human papillomavirus vaccine (2vHPV)
Quadrivalent human papillomavirus vaccine (4vHPV)
Meningococcal polysaccharide vaccine (MPSV4)
Zoster (shingles) vaccine live
Meningococcal conjugate vaccine, serogroups c & y and haemophilus influenza type b vaccine (hib-mency)
Meningococcal polysaccharide diphtheria toxoid conjugate vaccine (MenACWY-D)

Vaccines supplied by the state or federal entities are not eligible for reimbursement by the Company.

NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

For individuals currently receiving home care services, administration of COVID-19 vaccine is not eligible for separate reimbursement consideration from the home care visit.

EXPERIMENTAL/INVESTIGATIONAL

The following vaccines are considered experimental/investigational and, therefore, not covered as the ACIP has not issued a recommendation:

Influenza virus vaccine, pandemic formulation, live, for intranasal use
Influenza virus vaccine, pandemic formulation, split virus, preservative free, for intramuscular use
Influenza virus vaccine, pandemic formulation, split virus, adjuvanted, for intramuscular use
Influenza virus vaccine, pandemic formulation, split virus, for intramuscular use

Dengue Vaccine

The dengue vaccine, as a three-dose regimen, is considered experimental/investigational and, therefore, not covered for individuals younger than 9 years of age or individuals older than 16 years because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

Dengue vaccine, as a two-dose regimen, is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

Respiratory Syncytial Virus

Respiratory syncytial virus (RSV) immunization (i.e., nirsevimab-alip [Beyfortus]) is considered experimental/investigational and, therefore, not covered for individuals ages 24 months or older.

Respiratory syncytial virus vaccine, adjuvanted (Arexvy) is considered experimental/investigational and, therefore, not covered for individuals younger than 50 years of age.

Respiratory syncytial virus vaccine (Abrysvo) is considered experimental/investigational and, therefore, not covered for non-pregnant individuals younger than 60 years of age.

Respiratory syncytial virus vaccine (mRESVIA) is considered experimental/investigational and, therefore, not covered for individuals younger than 60 years of age.

Rotavirus Vaccine

Rotavirus vaccines (RV5 [RotaTeq] or RV1 [Rotarix]) are considered experimental/investigational when any of the following criteria are met:

Individual is older than 1 year of age
The number of doses has exceeded 3

Combination Vaccines

Vaxelis^TM, diphtheria and tetanus toxoids and acellular pertussis vaccine adsorbed, inactivated poliovirus, Hemophilus b conjugate and Hepatitis B vaccine (DTaP-IPV-Hib-HepB), is considered experimental/investigational for individuals ages 5 years or older.

Zoster (Shingles) Vaccine

Zoster (shingles) vaccine is considered experimental/investigational for individuals under 18 years.

Human Papillomavirus Vaccine

9-valent papillomavirus vaccine (9vHPV) is considered experimental/investigational for individuals younger than 9 years and individuals older than 45 years.

NON-ROUTINE/NON-PREVENTIVE VACCINES

MEDICALLY NECESSARY

Non-routine vaccines for the indications described below are considered medically necessary and, therefore, covered in accordance with Advisory Committee for Immunization Practices (ACIP) recommendations. In addition, vaccines approved by the FDA that have not been recognized by the ACIP are considered non-routine. The following vaccine indications are considered non-routine and non-preventive and are subject to applicable member cost sharing.

BCG Vaccine

Bacille Calmette-Guerin (BCG) vaccine is considered medically necessary and, therefore, covered for individuals when either of the following criteria are met:

For children who have a negative tuberculin skin test and who are continually exposed to, and cannot be separated from, adults who are untreated or ineffectively treated for tuberculosis (TB) disease (if the child cannot be given long-term treatment for infection).
For children who have a negative tuberculin skin test and who are continually exposed to, and cannot be separated from, adults who have TB caused by strains resistant to isoniazid and rifampin.

Pneumococcal Vaccine

13- valent Pneumococcal conjugate vaccine (PCV) is considered medically necessary and, therefore, covered for individuals.

21- valent Pneumococcal conjugate vaccine (PCV) is considered medically necessary and, therefore, covered for individuals 18 years of age.

Post-Exposure Rabies Vaccine

Post-exposure rabies vaccine, for intramuscular use, is considered medically necessary and, therefore, covered for the following individuals:

A four-dose regimen in combination with rabies immune globulin (RIG) for healthy individuals as treatment of an injury or direct exposure to rabies disease or condition.
A five-dose regimen with one dose of RIG for individuals with altered immunocompetence.

Preexposure Prophylaxis for Prevention of Anthrax Booster

An anthrax booster for the preexposure prophylaxis for prevention of anthrax every three years is considered medically necessary and, therefore, covered for individuals not at high risk for exposure for B. anthracis who previously completed the three dose primary series and the initial two dose booster series who want to maintain protection.

Respiratory Syncytial Virus Vaccine

Respiratory syncytial virus vaccine, adjuvanted (Arexvy) is considered medically necessary and, therefore, covered as a one-time dose regimen for individuals 50 through 59 years of age.

Tdap/Td Vaccines

Tdap or Td vaccine (tetanus toxoid-containing vaccine) is considered medically necessary and, therefore, covered for tetanus wound management for the following individuals:

For individuals with a history of three or more doses of absorbed tetanus toxoid vaccination:

Td vaccine (Tdap may be substituted for Td in individuals older than 10 years who have previously not received Tdap, or in individuals 7 to 10 years of age who are under-vaccinated against pertussis).

A booster dose of tetanus toxoid-containing vaccine if it has been more than 10 years since the last tetanus toxoid dose and the wound is clean and minor.
A booster dose of tetanus toxoid-containing vaccine if it has been 5 years or more since the last tetanus toxoid dose and the wound is other than clean and minor.

For individuals with an unknown history or a history of less than three doses of absorbed tetanus toxoid vaccination:

Td vaccine (Tdap for individuals older than 10 years who have previously not received Tdap, or in individuals 7 to 10 years of age who are under-vaccinated against pertussis).

Typhoid Vaccine

Typhoid vaccine is considered medically necessary and, therefore, covered for individuals with intimate exposure (e.g., household contact) to a documented Salmonella serotype Typhi chronic carrier (defined as excretion of Salmonella serotype Typhi in urine or stool for more than one year).

Zoster (Shingles) Vaccine

Recombinant zoster vaccine is considered medically necessary and, therefore, covered for individuals aged 18 years and older who are or will be at increased risk of herpes zoster due to immunodeficiency or immunosuppression caused by known disease or therapy.

EXPERIMENTAL/INVESTIGATIONAL

Rabies Vaccine

The rabies vaccine for intradermal use is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

TRAVEL-RELATED VACCINES

Travel-related vaccines are benefit contract exclusions for most plans, and therefore, not eligible for reimbursement consideration. Individual benefits must be verified.

Travel-related vaccines includes, but is not limited to, the following diseases:

Japanese encephalitis (JE)
Yellow fever (has country-specific requirements)
Cholera
Ebola
Tick-borne encephalitis
Chikungunya

There are additional vaccines, both routine and non-routine that are commonly, but not exclusively, used for travel purposes. When routine vaccines are used solely for travel-related purposes in accordance with the ACIP recommendations, the routine vaccines are considered medically necessary and, therefore, covered by the Company.

EMPLOYMENT/OCCUPATION-RELATED VACCINES

Vaccines used prophylactically for employment purposes, occupational requirements, or work-related injuries are benefit contract exclusions for most plans, and therefore, not eligible for reimbursement consideration. Individual benefits must be verified.

Vaccines include, but are not limited to, pre-exposure rabies vaccine.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, records from the professional providers' office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation must be made available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

Medical necessity criteria for preventive immunization are subject to change based on updated recommendations of the Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) as published in Morbidity and Mortality Weekly Report (MMWR).

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, vaccines are covered under the medical benefits of the Company's products when the medical necessity criteria listed in this medical policy are met.

MANDATES

This policy is consistent with applicable state and federal mandates. The laws of the state where the benefit contract is issued determine the mandated coverage, in addition to any applicable federal mandates.

BILLING GUIDELINES

ACIP has no additional recommendations for the usage of US Food and Drug Administration (FDA)–approved multiantigen combination vaccines over single-antigen vaccines or vice versa.

Vaccination is reimbursed per vaccine agent given as opposed to per vaccine injection administered. Multiple-antigen vaccine (e.g., MMRV [measles, mumps, rubella, varicella]) administered in one injection will receive equal amount of reimbursement as if the same components of the vaccine were to be injected separately.

PREVENTIVE VACCINE SERVICES

For members who have zero cost-share preventive services in accordance with the Patient Protection and Affordable Care Act (PPACA) of 2010 and the Health Care and Education Reconciliation Act (HCERA) of 2010, no cost-share (i.e., copayments, deductibles, coinsurance) will be applied to routine preventive vaccines (vaccine and administration) that are recommended by the Advisory Committee on Immunization Practices (ACIP).

Description

Vaccination is a deliberate attempt to protect individuals against infectious disease by both preventing disease in immunized individuals and creating barriers to the spread of infectious disease. Preventable, once-threatening diseases that are now controlled by vaccines include polio, measles, diphtheria, pertussis, rubella, mumps, and tetanus.

Individuals are born with some natural defense mechanisms against bacteria, viruses, and other infectious organisms: this is referred to as innate, nonspecific immunity and includes barrier methods such as the skin, antibodies received from the mother during gestation (passive immunity), and antibodies that develop in the neonate at 2 to 3 months of age. Acquired immunity is developed in response to infection or vaccination and is specific to the invading organism. Immunity induced by infection or vaccination is called active immunity. Immunity is established when memory cells develop and then detect invading organisms and defend against the original antigen during re-infection.

Actual vaccines contain weakened or killed antigens and are injected into fatty tissue or muscle. Without causing disease, these antigens prompt the immune system to produce antibodies against vaccine-preventable diseases. However, in some cases, as with the rabies vaccine, the vaccine is administered to provide postexposure prophylaxis against infection.

ROUTINE VACCINES 

Routine vaccines are vaccines that are included on the recommended immunization schedule published by the Advisory Committee on Immunization Practices (ACIP). The recommended immunization schedule is to be followed throughout an individual's lifespan. Vaccines given after the recommended immunization scheduled time are called catch-up immunizations. A catch-up regimen allows for the administration of the remaining doses of the vaccination to ensure that the individual continues to receive timely coverage against vaccine-preventable disease.

COVID VACCINE

COVID-19 vaccine provides protection against COVID-19 viruses that infect the nose, throat, and lungs, and cause contagious respiratory illness. COVID-19 viruses can cause mild to severe illness, and at times can lead to death. COVID-19 viruses are always changing, so vaccination may be recommended by the Centers for Disease Control and Prevention (CDC). Scientists try to match the viruses in the vaccine to those most likely to cause COVID-19 in a specific year.

DENGUE VACCINE

Dengue is a vector-borne infectious disease that is predominantly transmitted by Aedes aegypti and Aedes albopictus mosquitos. Dengue clinical presentation can range from a mild disease (e.g. mild, undifferentiated febrile illness) to severe illness (e.g., shock, bleeding, severe organ impairment), and at times can lead to death. The dengue vaccine is recommended by the ACIP for use in individuals 9 through 16 years of age with laboratory-confirmed previous dengue infection and living in endemic areas.

DIPHTHERIA, TETANUS, AND PERTUSSIS (DTAP)/TETANUS, DIPHTHERIA AND PERTUSSIS (TDAP)/ TETANUS, DIPHTHERIA (TD) VACCINES
Diphtheria, tetanus, and pertussis are serious diseases preventable by vaccination. Diphtheria can lead to respiratory difficulty, paralysis, heart failure, and even death. Tetanus causes painful muscle tightening and convulsive spasms of the skeletal muscle and fatal in about 1% of cases. Pertussis (whooping cough) can lead to pneumonia, seizures, brain damage, and death.

HAEMOPHILUS INFLUENZAE TYPE B VACCINE
Haemophilus influenzae type B (HiB) vaccine provides protection against Haemophilus influenzae type b, which primarily infects children under 5 years of age. HiB can cause meningitis and can lead to complications such as lasting brain damage, blindness, deafness, and death. Other complications of HiB include pneumonia, epiglottitis, and serious infections of blood, bones, joints, and the covering of the heart. Healthy children over 5 years of age usually do not need HiB vaccine.

HEPATITIS A VACCINE
Hepatitis A vaccine provides protection against hepatitis A virus (HAV), which causes an acute liver disease, lasting from a few weeks to several months. HAV does not lead to chronic infection. HAV is transmitted via ingestion of fecal matter, either from close person-to-person contact or from ingestion of contaminated food or drinks.

HEPATITIS B VACCINE
The hepatitis B vaccine provides protection against hepatitis B virus (HBV), which is a blood-borne and sexually transmitted virus. The complications of hepatitis B can lead to cirrhosis, liver cancer, liver failure, and death.

HUMAN PAPILLOMAVIRUS VACCINE
Human papillomavirus vaccine provides protection against genital human papillomavirus (HPV), which is the most common sexually transmitted infection in the United States. There are more than 40 HPV types that can infect the genital areas of male and female individuals. Rarely, these HPV types can also infect the mouth and throat. Although the majority of infections are asymptomatic and self-limited, persistent infection with oncogenic types can lead to cervical cancer. HPV infection can also cause genital warts and is associated with other anogenital cancers. There is one type of vaccine currently available, a 9-valent HPV vaccine (9vHPV). 9vHPV protects against HPV types 6,11,16,18, 31, 33, 45, 52, and 58. In November 2016, the last dose of the bivalent HPV vaccine expired. In May of 2017 the last doses of the quadrivalent HPV vaccine expired.

INFLUENZA VACCINE
Influenza vaccine provides protection against influenza viruses that infect the nose, throat, and lungs and cause contagious respiratory illness. Influenza viruses can cause mild to severe illness, and at times can lead to death. There are two main types of influenza (flu) virus: types A and B. The influenza A and B viruses that routinely spread in people (human influenza viruses) are responsible for seasonal flu epidemics each year. Influenza A viruses can be broken down into subtypes depending on the genes comprising the surface proteins. Over the course of a flu season, different types (A and B) and subtypes (influenza A) of influenza circulate and cause illness. Influenza viruses are always changing, so annual vaccination is recommended by the CDC. Scientists try to match the viruses in the vaccine to those most likely to cause flu that year. There are three types of influenza vaccines, inactivated (killed) influenza vaccine (IIV), recombinant influenza vaccine (RIV4), and live attenuated influenza vaccine (LAIV4). IIV and RIV4 are administered intramuscularly. LAIV4 is administered intranasally.

MEASLES, MUMPS, RUBELLA (MMR), AND VARICELLA VACCINES
Vaccines for measles, mumps, rubella, and varicella are crucial for preventing these serious diseases. Complications caused by measles virus are ear infection, pneumonia, seizures, brain damage, and death. Mumps virus can lead to deafness, meningitis, painful swelling of the testicles or ovaries, and, in rare cases, sterility. Rubella virus (German measles) contracted by a woman while she is pregnant can cause miscarriage or serious birth defects. Varicella (chicken pox) is a highly infectious disease caused by the varicella zoster virus (VZV). VZV can lead to severe skin infection, scars, pneumonia, brain damage, or death, and can re-emerge years later as shingles.

Children may be administered vaccines for measles, mumps, rubella, and varicella through two separate injections of MMR plus a separate injection of varicella vaccine, or they can be vaccinated with just one injection of the combination measles, mumps, rubella, and varicella vaccine (MMRV). Although MMRV has the benefit of one less injection than MMR plus varicella vaccine, it carries an increased risk for febrile seizures with the first dose for individuals who have a personal or family history of seizures.

MENINGOCOCCAL CONJUGATE AND MENINGOCOCCAL POLYSACCHARIDE VACCINES
Onset can be abrupt, and the course of disease is rapid. Meningococcal disease can lead to serious sequelae (a condition caused by previous disease), including deafness, neurologic deficit, limb loss or possibly death. Rates of meningococcal infection are the highest in infancy, with a second peak in adolescence, especially in individuals around 18 years of age. College freshmen living in dormitories are at higher risk than the general population of similar age.

The disease occurs in three common clinical forms:

Meningitis
Blood infection
Pneumonia

Meningococcal conjugate (MenACWY-CRM, MenACWY-TT, or MenACWY-TT/MenB-FHbp) vaccines provide protection against invasive meningococcal disease. In October 2023, the last dose of the meningococcal polysaccharide diphtheria toxoid conjugate (MenACWY-D) vaccine expired.

Some groups may be at increased risk for serogroup B meningococcal disease. Three serogroup B meningococcal vaccines have been licensed by the FDA: MenB-4C, MenB-FHbp, MenACWY-TT/MenB-FHbp.

MPOX AND SMALLPOX VACCINE

Mpox is a rare zoonotic infection caused by the Mpox virus, an orthopoxvirus, which is in the same family of viruses as the smallpox virus. Mpox presents with symptoms similar to smallpox, but milder. There are primarily two types of Mpox virus: Clade I and Clade II. Clade II currently has two subtypes: Clade IIa and Clade IIb.

The Advisory Committee of Immunizations Practices (ACIP) currently recommends pre-exposure prophylaxis for individuals at risk of occupational exposure to orthopoxviruses, which includes Mpox and smallpox, and for adults with risk factors for mpox exposure.

Postexposure prophylaxis can be considered after exposure to Mpox. The CDC recommends the vaccine be provided within 4 days from the exposure date to prevent disease onset. If the vaccine is provided between day 4 and 14 after exposure, the vaccination may still reduce the severity of Mpox infection.

The CDC recommends postexposure prophylaxis be considered for individuals who have been exposed or might be exposed to Mpox virus and who have not received an orthopoxvirus vaccine.

Currently, there are two FDA-approved vaccines for the prevention of orthopoxvirus infections.

PNEUMOCOCCAL VACCINE

Pneumococcal vaccine provides protection against Streptococcus pneumoniae, which can cause sinusitis, acute otitis media (AOM), bacteremia, meningitis, pneumonia, and death. In 2010, 13-valent pneumococcal polysaccharide-protein conjugate vaccine (PCV13) was approved by the FDA to replace 7-valent pneumococcal polysaccharide-protein conjugate vaccine (PCV7) for prevention of invasive pneumococcal disease (IPD). PCV13 contains the seven serotypes that are included in PCV7 (serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F), plus six additional serotypes (1, 3, 5, 6A, 7F, and 19A). The 23-valent pneumococcal polysaccharide vaccine (PPSV23) protects against 23 serotypes of pneumococcal bacteria. In June 2021, pneumococcal 20-valent conjugate (PCV20) vaccine was approved by the FDA for individuals 18 years of age or older. In July 2021, pneumococcal 15-valent conjugate (PCV15) vaccine was approved by the FDA for individuals 18 years of age or older. On June 22, 2022, PCV15 received FDA approval for individuals 6 weeks old and older. On April 27, 2023, PCV20 received FDA approval for individuals 6 weeks old and older. In September 2025, the last dose of PCV13 vaccine expires.

POLIO VACCINE

Polio, or poliomyelitis, is caused by three serotypes of poliovirus (types 1, 2, and 3). Illness appears in three forms: abortive polio, nonparalytic polio, and paralytic polio. Individuals who have abortive polio or nonparalytic polio can usually recover. However, paralytic polio can cause paralysis and death. Since 2000, ACIP has recommended exclusive use of inactivated poliovirus vaccine (IPV) for routine childhood polio vaccination. In addition, unvaccinated adults who are at increased risk should receive a primary vaccination series with IPV. Oral poliovirus vaccine (OPV) has been removed from the United States market since 2000 due to vaccine-associated paralytic poliomyelitis. ACIP only recommends IPV.

RESPIRATORY SYNCTITAL VIRUS VACCINE
Respiratory syncytial virus (RSV) causes annual respiratory illness outbreaks in all ages. Severe disease occurs in very young infants, adults with chronic lung or heart disease, adults with weakened immune systems, and individuals 65 years and older. On May 3, 2023, the FDA approved the first RSV (Arexvy) vaccine for individuals 60 years old and older. On May 31, 2023, RSV vaccine (Abrysvo) was FDA-approved for the prevention of lower respiratory tract disease caused by RSV in individuals 60 years of age and older. On July 17, 2023, nirsevimab-alip (Beyfortus) was FDA approved for the prevention of lower respiratory tract disease caused by RSV in neonates and infants born during or entering their first RSV season and children up to 24 months of age who remain vulnerable to severe RSV disease through their second RSV season. On August 22, 2023, RSV vaccine (Abrysvo) was FDA approved for pregnant individuals at 32 through 36 weeks gestational age for the prevention of lower respiratory tract disease and severe lower respiratory tract disease caused by RSV in infants from birth through 6 months of age. On June 7, 2024, RSV vaccine, adjuvanted (Arexvy) was FDA-approved for individuals aged 50 to 59 years old. On June 14, 2024, RSV vaccine (Mresvia) was approved by the FDA for the prevention of lower respiratory tract disease caused by RSV in individuals 60 years of age and older. On June 26, 2024, ACIP updated its RSV recommendations. ACIP recommends a single dose of the RSV vaccine for individuals 60 to 74 years of age who are at increased risk of severe RSV disease. ACIP recommends a single dose of the RSV vaccine for individuals 75 years of age and older.

ROTAVIRUS VACCINE

Rotavirus vaccine, administered orally, protects against rotavirus, a cause of common, severe gastroenteritis, which can result in the death of infants and young children. Two different rotavirus vaccines are currently available for use in infants in the United States and are given in a series of two or three doses, depending on which brand is used.

ZOSTER (SHINGLES) VACCINE

The zoster (shingles) vaccine protects against VZV. Infection with VZV causes herpes zoster (i.e., shingles), which consists of a painful cutaneous eruption that occurs most commonly among older adults. A complication of herpes zoster is postherpetic neuralgia (PHN), a chronic pain condition that can last years.

Since varicella vaccination in the United States did not begin until 1995, approximately 99.5% of those born in the United States who are 40 years of age and older have had the varicella virus via chicken pox, even if they do not remember. As a result, most older adults in the United States are at risk for herpes zoster. Because of this, health care providers do not need to inquire about the individual's varicella vaccination history before administering zoster vaccine. According to the CDC, "the number of persons eligible for zoster vaccination who have received varicella vaccine is extremely small and will remain so for at least a decade." In November 2020 the last dose of the zoster (shingles) vaccine live expired.

COMBINATION VACCINES

Combination vaccines are two or more vaccines given through one immunization. Combination vaccines reduce the number of shots administered while protecting against multiple serious diseases (e.g., diphtheria, tetanus, polio) and decreasing delays in disease protection.

NON-ROUTINE VACCINES

Non-routine vaccines, including rabies, anthrax, adenovirus, Bacille Calmette-Guérin (BCG), and typhoid vaccines, are excluded from the immunization schedule recommended by ACIP. Tetanus and diphtheria toxoids (Td) and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) have non-routine indications that are excluded from the immunization schedule recommended by ACIP and are therefore also considered non-routine vaccines under specific circumstances.

ANTHRAX VACCINE

Anthrax is an acute infectious disease caused by the spore-forming bacterium Bacillus anthracis. Anthrax most commonly occurs in wild and domestic animals (e.g., cattle, sheep, goats, and other herbivores), but it can also occur in humans when they are exposed to animals or tissue from animals infected with anthrax spores.

Bacillus anthracis has also been developed specifically as a biological warfare agent. Because the location and timing of a bioterrorism attack cannot be predicted, the risk-benefit profile for pre-event anthrax vaccination for the general public is low; thus, pre-event anthrax vaccination is not recommended by ACIP.

In December 2019, ACIP recommended that a booster dose of anthrax vaccine for pre-exposure prophylaxis for individuals who are not at high risk for exposure to B. anthracis who have previously completed the five-dose regimen of anthrax vaccine and want to maintain protection.

BCG VACCINE

Bacille Calmette-Guérin (BCG) is a vaccine for tuberculosis (TB). Many foreign-born individuals have been BCG vaccinated. Because the overall risk for acquiring Mycobacterium tuberculosis infection is low for the US population, routine BCG vaccination is not indicated. The BCG vaccine should be considered only for very select individuals who meet specific criteria and in consultation with a TB expert.

POST-EXPOSURE RABIES VACCINE

Rabies is a preventable viral disease of mammals most often transmitted through the bite of a rabid animal. The vast majority of rabies cases reported to the CDC each year occur in wild animals such as raccoons, skunks, bats, and foxes. The rabies virus infects the central nervous system, ultimately causing disease in the brain, and death. The early symptoms of rabies are similar to those of many other illnesses, including fever, headache, and general weakness or discomfort. As the disease progresses, more specific symptoms appear and may include insomnia, anxiety, confusion, slight or partial paralysis, excitation, hallucinations, agitation, hypersalivation (increase in saliva), difficulty swallowing, and hydrophobia (fear of water). Death usually occurs within days of the onset of these symptoms.

ACIP does not recommend pre-exposure prophylaxis against rabies for the general US population or for routine travelers to areas where rabies is not enzootic. However, for individuals who have never been vaccinated against rabies, post-exposure anti-rabies vaccination should be given as soon as possible following an exposure.

Presently, the FDA has only approved the intramuscular route of administration for rabies vaccine.

TDAP/TD VACCINES
In addition to ACIP's routine recommended immunization schedule, TDAP/TD vaccines also provide protection for non-routine indications. Tetanus is caused by a toxin produced by the bacterium Clostridium tetani (C. tetani). C. tetani produces spores that are very difficult to kill. C. tetani spores are found in the soil, the intestines, and the feces of many household farm animals and humans. The bacteria enter the human body through a puncture wound. Wound treatment for tetanus depends on an individual's vaccination status and the nature of the wound (e.g., severe versus minor and/or contaminated versus clean). With wounds that involve the possibility of tetanus contamination, an individual with an unknown or incomplete history of tetanus vaccination needs a Td or Tdap injection and a dose of tetanus immune globulin (TIG) as soon as possible. An individual with a documented series of three Td or Tdap who has received a booster dose within the last 10 years should be protected. However, to ensure adequate protection, a booster dose of vaccine may still be given if it has been more than 5 years since the last dose and the wound is other than clean and minor.

TYPHOID VACCINE

Typhoid fever is a potentially severe and occasionally life-threatening febrile illness caused by the bacterium Salmonella enterica serotype Typhi. It is most commonly transmitted from water or food contaminated by the feces of an infected individual. It is uncommon in the United States, with an average of 5700 cases each year.

TRAVEL-RELATED VACCINES

Certain vaccines are used exclusively for travel purposes, while still other vaccines (both routine and non-routine) that are a part of the recommended immunization schedule or have non-routine indications under specific circumstances are used for travel purposes.

Travel-related vaccines (e.g., yellow fever) should be considered in order to protect travelers from illnesses present in other parts of the world and to prevent the importation of infectious diseases across international borders. Which vaccines are needed depends on a number of factors, including the individual's destination, whether the individual will be spending time in rural areas, the season of the year the individual is traveling, and the individual's age, health status, and previous immunizations. Some countries require travelers to carry proof of vaccination on an International Certificate of Vaccination or Prophylaxis (ICVP) to enter the country; however, requirements can change at any time.

EMPLOYMENT/OCCUPATION-RELATED VACCINES

ACIP recommends vaccination for certain high-risk groups at risk for exposure to and possible transmission of vaccine-preventable diseases. Certain routine vaccines (e.g., hepatitis B vaccine for health care personnel) and non-routine vaccines (e.g., adenovirus vaccine for military personnel) will be required and/or recommended by an employer.

References

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Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Use of Updated COVID-19 Vaccines 2023–2024 Formula for Persons Aged ≥6 Months: Recommendations of the Advisory Committee on Immunization Practices — United States, September 2023. [CDC Web site]. 10/20/2023. Available at: https://www.cdc.gov/mmwr/volumes/72/wr/mm7242e1.htm. Accessed June 7, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Yellow Fever Vaccine Booster Doses: Recommendations of the Advisory Committee on Immunization Practices, 2015. [CDC Web site]. 06/19/2015. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6423a5.htm. Accessed June 7, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). The Role of BCG Vaccine in the Prevention and Control of Tuberculosis in the United States a Joint Statement by the Advisory Council for the Elimination of Tuberculosis and the Advisory Committee on Immunization Practices. [CDC Web site]. 04/26/1996. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/00041047.htm. Accessed June 7, 2024.

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Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Use of Ebola Vaccine: Expansion of Recommendations of the Advisory Committee on Immunization Practices To Include Two Additional Populations — United States, 2021. [CDC Web site]. 02/25/2022. Available at: https://www.cdc.gov/mmwr/volumes/71/wr/mm7108a2.htm. Accessed June 14, 2024.

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Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Universal Hepatitis B Vaccination in Adults Aged 19–59 Years: Updated Recommendations of the Advisory Committee on Immunization Practices — United States, 2022. [CDC Web site]. 04/01/2022. Available at: https://www.cdc.gov/mmwr/volumes/71/wr/mm7113a1.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Measles, Mumps, Rubella Vaccine (PRIORIX): Recommendations of the Advisory Committee on Immunization Practices — United States, 2022. [CDC Web site]. 11/18/2022. Available at: https://www.cdc.gov/mmwr/volumes/71/wr/mm7146a1.htm. Accessed June 14, 2024.

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Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Use of Inactivated Polio Vaccine Among U.S. Adults: Updated Recommendations of the Advisory Committee on Immunization Practices — United States, 2023. [CDC Web site]. 12/08/2023. Available at: https://www.cdc.gov/mmwr/volumes/72/wr/mm7249a3.htm. Accessed June 14, 2024.

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Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Tick-Borne Encephalitis Vaccine: Recommendations of the Advisory Committee on Immunization Practices, United States, 2023. [CDC Web site]. 11/10/2023. Available at: https://www.cdc.gov/mmwr/volumes/72/rr/rr7205a1.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Use of Recombinant Zoster Vaccine in Immunocompromised Adults Aged ≥19 Years: Recommendations of the Advisory Committee on Immunization Practices — United States, 2022. [CDC Web site]. 01/21/2022. Available at: https://www.cdc.gov/mmwr/volumes/71/wr/mm7103a2.htm. Accessed June 14, 2024.

Advisory Committee on Immunization Practices (ACIP) Recommended Immunization Schedule for Persons for ages 18 years or younger— United States, 2023. [CDC Web site]. 11/16/2023. Available at: https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html. Accessed June 14, 2024.

Advisory Committee on Immunization Practices (ACIP) Recommended Immunization Schedule for Adults Aged 19 Years and Older – United States, 2023. [CDC Web site]. 02/29/2024. Available at: https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP) — United States, 2023-24 Influenza Season. [CDC Web site]. 08/25/2023. Available at: https://www.cdc.gov/mmwr/volumes/72/rr/rr7202a1.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Use of a Modified Preexposure Prophylaxis Vaccination Schedule to Pr event Human Rabies: Recommendations of the Advisory Committee on Immunization Practices-- United States 2022. [CDC Web site]. 05/06/2022. Available at: https://www.cdc.gov/mmwr/volumes/71/wr/mm7118a2.htm. Accessed June 14, 2024

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Use of 15-Valent Pneumococcal Conjugate Vaccine Among U.S. Children: Updated Recommendations of the Advisory Committee on Immunization Practices — United States, 2022. [CDC Web site].09/16/2022. Available at: https://www.cdc.gov/mmwr/volumes/71/wr/mm7137a3.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Progress Toward Polio Eradication--Worldwide, January 2020-April 2020. [CDC Web site]. 05/13/2022. Available at: https://www.cdc.gov/mmwr/volumes/71/wr/mm7119a2.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Use of JYNNEOS (Smallpox and Monkeypox Vaccine, Live, Nonreplicating) for Preexposure Vaccination of Persons at Risk for Occupational Exposure to Orthopoxviruses: Recommendations of the Advisory Committee on Immunization Practices — United States, 2022. [CDC Web site]. 06/03/2022. Available at: https://www.cdc.gov/mmwr/volumes/71/wr/mm7122e1.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). BCG vaccine. [CDC Web site]. 05/04/2016. Available at: http://www.cdc.gov/tb/publications/factsheets/prevention/BCG.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). General recommendations on immunization General Best Practice Guidelines for Immunization. [CDC Web site]. 08/01/2023. Available at: https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Licensure of a Diphtheria and Tetanus Toxoids and Acellular Pertussis, Inactivated Poliovirus, Haemophilus influenzae Type b Conjugate, and Hepatitis B Vaccine, and Guidnace for use in Infants. [CDC Web site]. 02/07/2020. Available at: https://www.cdc.gov/mmwr/volumes/69/wr/mm6905a5.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Prevention of Hepatitis A Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices, 2020. [CDC Web site]. 07/03/2020. Available at: https://www.cdc.gov/mmwr/volumes/69/rr/rr6905a1.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Food and Drug Administration Approval of Use of Hiberix as a 3-Dose Primary Hemophilus influenzae Type b (Hib) Vaccination Series. [CDC Web site]. 04/29/2016. Available at: https://www.cdc.gov/mmwr/volumes/65/wr/mm6516a3.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Meningococcal Vaccination: Recommendations of the Advisory Committee on Immunization Practices, United States, 2020. [CDC Web site]. 09/25/2020. Available at: https://www.cdc.gov/mmwr/volumes/69/rr/rr6909a1.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Addition of History of Intussusception as a Contraindication for Rotavirus Vaccination. [CDC Web site]. 10/21/2011. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6041a5.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Addition of Severe Combined Immunideficiency as a Contraindication for Rotavirus Vaccination. [CDC Web site]. 06/11/2010. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5922a3.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Human papillomavirus vaccination: Recommendations of the Advisory Committee on Immunization Practices (ACIP). [CDC Web site]. 08/29/2014. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6305a1.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Human rabies prevention --- United States, 2008. [CDC Web site]. 05/23/08. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5703a1.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Poliomyelitis prevention in the United States. [CDC Web site]. 05/19/00. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4905a1.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Prevention of herpes zoster. [CDC Web site]. 06/06/08. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5705a1.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013 Summary. Recommendations of the ACIP. [CDC Web site]. 06/14/2013. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6204a1.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Prevention of rotavirus gastroenteritis among infants and children. [CDC Web site]. 02/06/09. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5802a1.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Prevention of varicella: Recommendations of the ACIP. [CDC Web site]. 06/22/07. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5604a1.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Prevention and control of Haemophilus influenza Type b disease. Recommendations of the Advisory Committee on Immunization Practices (ACIP). [CDC Web site]. 02/28/2014. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6301a1.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices. [CDC Web site]. 01/12/2018. Available at: https://www.cdc.gov/mmwr/volumes/67/rr/rr6701a1.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. [CDC Web site]. 01/26/2018. Available at: https://www.cdc.gov/mmwr/volumes/67/wr/mm6703a5.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Updated recommendations for the use of typhoid vaccine. [CDC Web site]. 03/27/2015. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6411a4.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Updated recommendations for the use of a VariZIG---United States, 2013. [CDC Web site]. 07/19/2013. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6228a4.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Updated recommendations of the Advisory Committee on Immunization Practices (ACIP) regarding routine poliovirus vaccination. [CDC Web site]. 08/07/09. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5830a3.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Use of anthrax vaccine in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2019. [CDC Web site]. 12/13/19. Available at: https://www.cdc.gov/mmwr/volumes/68/rr/rr6804a1.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Use of combination measles, mumps, rubella, and varicella vaccine. [CDC Web site]. 05/07/10. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5903a1.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Use of a reduced (4-dose) vaccine schedule for postexposure prophylaxis to prevent human rabies. [CDC Web site]. 03/19/10. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5902a1.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Use of 9-valent human papillomavirus (HPV) vaccine: updated HPV vaccination recommendations of the Advisory Committee on Immunization Practices. [CDC Web site]. 03/27/2015. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6411a3.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Vaccinia (smallpox) vaccine. [CDC Web site]. 06/22/01. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5010a1.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Recommendations of the Advisory Committee on Immunization Practice for Use of Cholera Vaccine. [CDC Web site]. 05/12/2017. Available at: https://www.cdc.gov/mmwr/volumes/66/wr/mm6618a6.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccines: Updated Recommendations of the Advisory Committee on Immunization Practices- United States, 2019. [CDC Web site]. 01/24/2020. Available at: https://www.cdc.gov/mmwr/volumes/69/wr/mm6903a5.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Prevention of Pertussis, Tetanus, and Diphtheria with Vaccines in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP). [CDC Web site]. 04/27/2018. Available at: https://www.cdc.gov/mmwr/volumes/67/rr/rr6702a1.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Recommendations of the Advisory Committee on Immunization Practices for Use of Hepatitis B Vaccine with a Novel Adjuvant. [CDC Web site]. 04/20/2018. Available at: https://www.cdc.gov/mmwr/volumes/67/wr/mm6715a5.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Use of a 2-Dose Schedule for Human Papillomavirus Vaccination-Updated Recommendations of the Advisory Committee on Immunization Practices. [CDC Web site]. 12/16/2016. Available at: https://www.cdc.gov/mmwr/volumes/65/wr/mm6549a5.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Human Papillomavirus Vaccination for Adults: Updated Recommendations of the Advisory Committee on Immunization Practices. [CDC Web site]. 08/16/2019. Available at: https://www.cdc.gov/mmwr/volumes/68/wr/mm6832a3.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Japanese Encephalitis Vaccine: Updated Recommendations of the Advisory Committee on Immunization Practices. [CDC Web site]. 07/19/2019. Available at: https://www.cdc.gov/mmwr/volumes/68/rr/rr6802a1.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). Use of 13-valent Pneumococcal Conjugate Vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged ≥ 65 years: Updated Recommendations of the Advisory Committee on Immunization Practices. [CDC Web site]. 11/22/19. Available at: https://www.cdc.gov/mmwr/volumes/68/wr/mm6846a5.htm. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). The pre-travel consultation. CDC Yellow Book 2024. [CDC Web site]. 05/01/2023. Available at: https://wwwnc.cdc.gov/travel/yellowbook/2020/preparing-international-travelers/the-pretravel-consultation. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Travelers' health. Vaccinations. [CDC Web site]. Available at: http:// wwwnc.cdc.gov/travel. Accessed June 14, 2024.

Centers for Disease Control and Prevention (CDC). Vaccine information statements. [CDC Web site]. 05/12/2023. Available at: https://www.cdc.gov/vaccines/hcp/vis/index.html.Accessed June 14, 2024.

Kroger A, M Freedman Travelers' Health: Vaccination & Immunoprophylaxis- General Principles. [CDC Web site]. 05/01/2023. Available at: https://wwwnc.cdc.gov/travel/yellowbook/2024/preparing/vaccination-and-immunoprophylaxis-general-principles Accessed June 14, 2024.

U.S. Food & Drug Administration (FDA). Vaccines Licensed for Use in the United States. [FDA Web site]. 06/01/2023. Available at: https://www.fda.gov/vaccines-blood-biologics/vaccines/vaccines-licensed-use-united-states. Accessed June 14, 2024.

Coding

CPT Procedure Code Number(s)

MEDICALLY NECESSARY

IMMUNIZATION ADMINISTRATION

90460

90461

90471

90472

90473

90474

90480

96380

96381

VACCINES

90581

90585

90587

90611

90619

90620

90621

90623

90630

90632

90633

90636

90647

90648

90651

90653

90654

90655

90656

90657

90658

90660

90661

90662

90670

90671

90672

90673

90674

90675

90677

90678

90679

90680

90681

90682

90683

90684

90685

90686

90687

90688

90689

90690

90691

90694

90696

90697

90698

90700

90702

90707

90710

90713

90714

90715

90716

90723

90732

90739

90740

90743

90744

90746

90747

90748

90750

90756

90759

91304

91318

91319

91320

91321

91322

THE FOLLOWING CODES REPRESENT NIRSEVIMAB-ALIP (BEYFORTUS™)

90380

90381

NOT ELIGIBLE FOR REIMBURSEMENT

90622

THE FOLLOWING VACCINE CODES ARE NO LONGER MANUFACTURED AND HAVE BEEN WITHDRAWN FROM THE MARKET:

90634

90644

90649

90650

90733

90734

90736

BENEFIT EXCLUSION

90476

90477

90589

90625

90626

90627

90717

90738

90758

EXPERIMENTAL/INVESTIGATIONAL

90584

90637

90638

90664

90666

90667

90668

90676

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

Report the most appropriate diagnosis code in support of medically necessary criteria as listed in the policy.

HCPCS Level II Code Number(s)

MEDICALLY NECESSARY

IMMUNIZATION ADMINISTRATION

G0008 Administration of influenza virus vaccine

G0009 Administration of pneumococcal vaccine

G0010 Administration of hepatitis B vaccine

J3530 Nasal vaccine inhalation

VACCINES

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)

Q2039 Influenza virus vaccine, not otherwise specified

NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

M0201 Administration of pneumococcal, influenza, hepatitis B, and/or COVID-19 vaccine inside a patient's home; reported only once per individual home per date of service when such vaccine administration(s) are performed at the patient's home

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub
Modifiers

NOT ELIGIBLE FOR REIMBURSEMENT

SL State supplied vaccine

Coding and Billing Requirements

Cross Reference

Policy History

Revisions from 08.01.04ag

07/01/2025

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

This policy has been identified for the CPT code update, effective 07/01/2025.

The following CPT narrative has been revised in this policy: 90620

Revisions from 08.01.04af

01/01/2025

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

This policy has been identified for the CPT code update, effective 01/01/2025.
The following CPT code has been added to this policy as benefit exclusion: 90593

The following CPT codes have been termed (no longer valid code) from this policy: 90630, 90654

The following CPT narrative has been revised in this policy: 90661

Revisions From 08.01.04ae:

11/18/2024

The policy criteria were updated as follows:

Routine/preventive vaccines

Medically necessary criteria were updated for the following:

DTaP/Tdap/Td vaccines
hepatitis A vaccine
hepatitis B vaccine
measles, mumps, rubella, and varicella vaccines.
meningococcal conjugate vaccines.
pneumococcal vaccine.
respiratory syncytial virus vaccine.

PCV13 and MenACWY-D coverage positions have been updated to not eligible for reimbursement.

Nonroutine/nonpreventive vaccines

The medically necessary criteria were updated for pneumococcal vaccine.
The medically necessary criteria were updated for RSV vaccine to add mRESVIA vaccine.

Travel vaccine criteria were updated to add the chikungunya vaccine.

Revisions From 08.01.04ad:

07/01/2024

Inclusion of a policy in a Code Update memo does not imply that a full review of

the policy was completed at this time.

This policy has been identified for the CPT code update, effective 07/01/2024.

The following CPT codes have been added to this policy as experimental/investigational: 90637, 90638. 90684

As previously communicated through a news aritcle, the COVID-19 vaccine coverage position was updated for individuals 65 years of age and older.

As previously communicated through a news aritcle, retroactively effective June 27, 2023, PCV20 was added as a routine medically necessary vaccine for children.

As previously communicated through a news aritcle, the following coverage positions were added for the respiratory syncytial virus (RSV) immunization (i.e., nirsevimab-alip [Beyfortus]), respiratory syncytial virus vaccine, adjuvanted [Arexvy] and respiratory syncytial virus vaccine [Abrysvo].

Retroactively effective to June 21, 2023, preventive coverage was added for individuals 60 years of age and older.
Retroactively effective to August 3, 2023, medically necessary and preventive coverage was added for pediatric individuals.
Retroactively effective to September 22, 2023, medically necessary and preventive coverage was added for pregnant individuals at 32 through 36 weeks gestational age.
As previously communicated, a billing requirement was added to require a maternity diagnosis code when the vaccine is provided to pregnant individuals.

As previously communicated through a news article, retroactively effective to October 26, 2023, the smallpox and Mpox vaccine coverage position was updated to medically necessary for individuals 18 years and older who are at risk for Mpox.

As previously communicated, retroactively effective November 1, 2023, the following codes have been terminated (i.e., no longer valid) and removed from the policy:

From the Medically Necessary Section: 0041A, 0042A, 0044A, 0121A, 0124A, 0134A, 0141A, 0142A, 0144A, 0151A , 0154A, 0164A, 0171A, 0172A, 0173A, 0174A

From the Not Medically Necessary Section: 0001A, 0002A, 0003A, 0004A, 0011A, 0012A, 0013A, 0051A, 0052A, 0053A, 0054A, 0064A, 0071A, 0072A, 0073A, 0074A, 0081A, 0082A, 0083A, 0091A, 0092A, 0093A, 0094A, 0111A, 0112A, 0113A

From the Not Eligible for Reimbursement Section: 0031A, 0034A, 91303

As previously communicated, the following codes were added to the medically necessary section:

Retroactively effective September 11, 2023: 90480, 91318, 91319, 91320, 91321, 91322
Retroactively effective to October 3, 2023: 91304
Retroactively effective to October 6, 2023: 90380, 90381, 96380, 96381
Retroactively effective to October 26, 2023: 90623

As previously communicated, October 26, 2023, the position of the following code changed from not eligible for reimbursement to eligible: 90611

Revisions From 08.01.04ac:

08/01/2023

This version of the policy will become effective 08/01/2023.

The policy criteria were updated as follows:

Routine/Preventive vaccines

Medically necessary criteria was added for the administration of bivalent COVID-19 vaccine
Not medically necessary criteria was added for monovalent COVID-19 vaccines
Not eligible for reimbursement criteria was added for Janssen COVID-19 vaccine
Not eligible for separate reimbursement criteria was added for the administration of COVID-19 vaciine in a home setting.
As previously communicated through a news article, pneumococcal vaccine criteria was updated to add PCV15 to the routine and catch-up schedule.
As previously communicated through a news article, the Wuhan strain monovalent COVID-19 vaccines was added to this policy as not medically necessary.

Nonroutine/Nonpreventive Vaccines

Medically necessary criteria was added for respiratory syncytial virus vaccine.
Medically necessary criteria was added for the administration of the MPox and smallpox vaccine
As previoulsy communicated through a news article, Janssen COVID-19 vaccine was added to the policy as not eligible for reimbutsement.
As previoulsy communicated through a news article, not eligible for reimbursement criteria was added for the MPox and smallpox Vaccine products.
As previoulsy communicated through a news article, PCV20 criteria was updated to expand the eligible age range.

The following codes have been added to the policy:

As medically necessary: 90678, 90679, 0041A, 0042A, 0044A, 0121A, 0124A, 0134A, 0141A, 0142A, 0144A, 0151A, 0154A, 0164A, 0171A, 0172A, 0173A, 0174A
As not medically necessary: 0001A, 0002A, 0003A, 0004A, 0011A, 0012A, 0013A, 0051A, 0052A, 0053A, 0054A, 0064A, 0071A, 0072A, 0073A, 0074A, 0081A, 0082A, 0083A, 0091A, 0092A, 0093A, 0094A, 0111A, 0112A, 0113A
As not eligible for reimbursement: 90611, M0201
As represent Janssen COVID-19 vaccine, which is no longer manufactured and has been withdrawn from the market: 0031A, 0034A

Revisions From 08.01.04ab:

01/01/2023

This version of the policy will become effective 01/01/20223

Dengue vaccine was added as a routine vaccine. The medically necessary criteria was updated for measles, mumps, rubella, and varicella. As previously communicated through a news article, effective January 21, 2022, the medically necessary criteria was updated for pnemococcal, and zoster. The not medically necessary cirteria was updaed for rabies.

Revisions From 08.01.04aa:

07/01/2022

Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time.

This policy has been identified for the CPT code update, effective 07/01/2022.

The following CPT code has been added to this policy as experimental/investigational: 90584.

Revisions From 08.01.04z:

01/01/2022

This version of the policy will become effective 01/01/2022.

The title of the policy was changed from Immunziations to Routine/Non-routine Vaccines.The policy criteria was updated to change the position of zoster vaccine live (Zostavax) and meningococcal conjugate vaccine serogroup c & y and heamophilis influenza type b vaccine from medically necessary to no longer manufactured and have been withdrawn from the market.

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On 12/22/2021, the policy in Notification has been updated to add the following CPT code, effective 01/01/2022, as medically necessary: 90759

Revisions From 08.01.04y:

10/11/2021

This version of the policy will become effective 10/11/2021.

The policy criteria was updated to add pneumococcal 15-valent conjugate vaccine and pneumococcal 20-valent conjugate vaccine as a non-routine eligible vaccine. The tick-borne encephalitis was added to the travel-related vaccines sections.

The following codes were added to the policy as medically necessary: 90671, 90677

The following codes were added to the policy as benefit exclusion: 90626, 90627

Revisions From 08.01.04x:

07/01/2021

This version of the policy will become effective 07/01/2021.

The policy criteria was updated to remove zoster vaccine live from medically necessary since it was been withdrawn from the market. The coverage position for meningococal polysaccharide vaccine has been changed from medically necessary to not eligible for reimbursement since it was been withdrawn from the market.

The coverage position for the following code was changed from medically necessary to not eligible for reimbursement: 90733

The following code was added to the policy as a benefit exclusion: 90758

Revisions From 08.01.04w:

09/14/2020

This version of the policy will become effective 09/14/2020.
The policy criteria were updated as follows:

The medically necessary criteria for the following routine vaccines were updated:

Hepatitis A Vaccine
Hepatitis B Vaccine
Human Papillomavirus Vaccine
Influenza Vaccine
Measles, Mumps, Rubella, and Varicella Vaccines
Meningococcal Conjugate and Meningococcal Pneumococcal Vaccine Polysaccharide Vaccines
Serogroup B meningococcal vaccine

Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Hemophilus influenza type b PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-HibHepB), for intramuscular use was removed from experimental/investigational.
Pre-exposure prophylaxis for the prevention of anthrax booster was added under non-routine vaccines medically necessary section.
Pre-event anthrax vaccine was removed from not medically necessary
Travel-related vaccines criteria was updated to remove typhoid vaccine. Ebola vaccine was added to travel-related vaccines.

The following codes were added as medically necessary: 90581, 90697, 90587. (90587 was communicated through a newsflash as medically necessary and preventive.)
The following codes were removed from experimental/investigational: 90587, 90619, 90697
The following code was removed as not medically necessary: 90581.
The following code was added as a benefit exclusion: 90749

The following modifier was added as not eligible for reimbursement: SL

Revisions From 08.01.04v:

01/01/2020

This version of the policy will become effective 01/01/2020.

The policy criteria were updated to change the position of bivalent human papillomavirus vaccine (2vHPV) and quadrivalent human papillomavirus vaccine (4vHPV) from medically necessary to not eligible for reimbursement.
The policy criteria for pneumococcal vaccine was updated to include an updated recommendation based on shared clinical decision-making, as well as to include the previously communicated coverage update for the following vaccines:

Human papillomavirus vaccine coverage was expanded to include individuals 27 years through 45 years.
Serogroup B meningococcal booster vaccine coverage

The following CPT code has been added to the policy: 90694

Revisions From 08.01.04u:

07/01/2019

The policy criteria was updated to:

Include an additional statement to address outbreaks for meningococcal and mumps, measles, rubella vaccines.
Include new recommendations from Advisory Committee on Immunization Practices (ACIP) for Hemophilus influenzae B, Hepatitis A Vaccine, meningococcal vaccines, pnuemococcal vaccine, and polio vaccine.

The following codes position was changed from not eligible for reimbursement to eligible:
90654, 90660, Q2034, Q2039.

Revisions From 08.01.04t:

01/01/2019

The following CPT code has been added to this policy: 90689

Revisions From 08.01.04s:

09/03/2018

This version of the policy will become effective 09/03/2018. The policy criteria were updated to include travel recommendations for routine vaccinations. Policy criteria were also updated to include live attenuated influenza vaccine as a medically necessary vaccine. The following code position was changed from not medically necessary to medically necessary: 90672.

Revisions From 08.01.04r:

05/21/2018

The policy criteria was updated to include new recommendations from Advisory Committee on Immunization Practices (ACIP) for Hepatitis B Vaccine and Measles, Mumps, Rubella, and Varicella Vaccine.

Revisions From 08.01.04q:

01/01/2018

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.
The following CPT code has been added to this policy: 90756
The following changes were made through a newsflash:

The following codes were moved from E/I to MN: 90750, 90739
The newsflash communicated 90750 is medically necessary for individuals 50 years and older.

Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date:

7/1/2025

Version Issued Date:

7/1/2025

Version Reissued Date:

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