CLINICAL POLICY

VACCINES
Policy Number: VACCINES 005.38 T0
Effective Date: October 1, 2013
Table of Contents

Page

CONDITIONS OF COVERAGE...................................
COVERAGE RATIONALE...........................................
BENEFIT CONSIDERATIONS....................................
BACKGROUND...........................................................
APPLICABLE CODES.................................................
REFERENCES............................................................
POLICY HISTORY/REVISION INFORMATION...........

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Related Policies:
Preventive Care

The services described in Oxford policies are subject to the terms, conditions and limitations of the
Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare
Advantage enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without
prior written notice unless otherwise required by Oxford's administrative procedures or applicable state law.
The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these
policies.
Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the
Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there
are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between
any policy and the Members plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of
Coverage will govern.

CONDITIONS OF COVERAGE
Applicable Lines of Business/Products

This policy applies to Oxford Commercial plan

membership

Benefit Type

General benefits package

Referral Required

No

(Does not apply to non-gatekeeper products)

No

Authorization Required
(Precertification always required for inpatient admission)

Precertification with Medical Director

Review Required

No

Applicable Site(s) of Service

All

(If site of service is not listed, Medical Director review is

required)

Note: Pneumococcal and influenza vaccines will be reimbursed regardless of the provider or
setting in which they are furnished.

Vaccinations: Clinical Policy (Effective 10/01/2013)

1996-2013, Oxford Health Plans, LLC

COVERAGE RATIONALE
Oxford provides coverage for immunizations/vaccinations except where specifically excluded.
Examples of the most common coverage exclusions include immunizations that are required for
travel, employment, education, insurance, marriage, adoption, military service, or other
administrative reasons. Refer to the Member's specific certificate of coverage, evidence of
coverage, summary of benefits and/or health benefits plan documentation for additional
information.
Immunizations that are not classified as a "coverage exclusion" by the Member's plan are
considered covered after all of the following conditions are satisfied:
1. US Food and Drug Administration (FDA) approval; and
2. Advisory Committee on Immunization Practices (ACIP) definitive ("shall") recommendation
rather a permissive ("may") recommendation published in the Morbidity & Mortality Weekly
Report (MMWR) of the Centers for Disease Control and Prevention (CDC).
BENEFIT CONSIDERATIONS
The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control
and Prevention (CDC) web site contains the most current information regarding the use of
vaccines and immunizations in the United States, including both recommendations/schedules and
precautions.

ACIP Recommendations: http://www.cdc.gov/vaccines/pubs/ACIP-list.htm

Oxford further provides coverage for re-vaccination and off schedule vaccinations as determined
appropriate by the Member's physician or other healthcare practitioner.
Oxford covers certain services under the Preventive Care Services benefit. Effective for plan
years on or after September 23, 2010, the federal Patient Protection and Affordable Care Act
(PPACA) requires non-grandfathered plans to cover certain preventive services identified by
PPACA. For non-grandfathered plans, and for grandfathered plans wishing to offer such
coverage, Oxford will cover preventive services as mandated by Federal Patient Protection and
Affordable Care Act (PPACA), with no cost sharing when provided by a network provider for
those vaccines with a definitive approval from ACIP of the CDC.
Refer to policy: Preventive Care for more information related to immunizations/vaccinations.
BACKGROUND
Disease prevention is extremely important in the realm of public health. Vaccines prevent disease
in the people who receive them and protect those who come into contact with unvaccinated
individuals. Vaccines are responsible for the control of many infectious diseases that were once
common in the United States, including polio, measles, diphtheria, pertussis (whooping cough),
rubella (German measles), mumps, tetanus, and Haemophilus influenzae type b (Hib).
Immunization, also known as vaccination, is a means of triggering acquired immunity. This is a
specialized form of immunity that provides long-lasting protection against specific antigens, such
as certain diseases. Small doses of an antigen (such as dead or weakened live viruses) are given
to activate the body's immune system
APPLICABLE CODES
The codes listed in this policy are for reference purposes only. Listing of a service or device code
in this policy does not imply that the service described by this code is a covered or non-covered
health service. Coverage is determined by the Members plan of benefits or Certificate of
Coverage. This list of codes may not be all inclusive.
Vaccinations: Clinical Policy (Effective 10/01/2013)
2
1996-2013, Oxford Health Plans, LLC

Immunization Administration
Applicable CPT/HCPCS Codes
CPT Code
90460

90461

90471
90472
90473
90474

HCPCS
Code
G0008
G0009
G0010

Description
Immunization administration through 18 years of age via any route of
administration, with counseling by physician or other qualified health care
professional; first or only component of each vaccine or toxoid administered
Immunization administration through 18 years of age via any route of
administration, with counseling by physician or other qualified health care
professional; each additional vaccine or toxoid component administered (List
separately in addition to code for primary procedure)
Immunization administration (includes percutaneous, intradermal, subcutaneous,
or intramuscular injections); one vaccine (single or combination vaccine/toxoid)
Immunization administration (includes percutaneous, intradermal, subcutaneous,
or intramuscular injections); each additional vaccine (single or combination
vaccine/toxoid) (List separately in addition to code for primary procedure)
Immunization administration by intranasal or oral route; one vaccine (single or
combination vaccine/toxoid)
Immunization administration by intranasal or oral route; each additional vaccine
(single or combination vaccine/toxoid) (List separately in addition to code for
primary procedure)
Description
Administration of influenza virus vaccine
Administration of pneumococcal vaccine
Administration of hepatitis B vaccine

CPT is a registered trademark of the American Medical Association

Vaccination Products
Applicable CPT/HCPCS Codes
CPT Code
90375
90376
90476
90477
90585
90586
90632
90633
90634
90636
90645
90646
90647

Description
Rabies immune globulin (RIg), human, for intramuscular and/or subcutaneous
use
Rabies immune globulin, heat-treated (RIg-HT), human, for intramuscular and/or
subcutaneous use
Adenovirus vaccine, type 4, live, for oral use
Adenovirus vaccine, type 7, live, for oral use
Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for percutaneous
use
Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, for intravesical
use
Hepatitis A vaccine, adult dosage, for intramuscular use
Hepatitis A vaccine, pediatric/adolescent dosage-2 dose schedule, for
intramuscular use
Hepatitis A vaccine, pediatric/adolescent dosage-3 dose schedule, for
intramuscular use
Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular
use
Hemophilus influenza b vaccine (Hib), HbOC conjugate (4 dose schedule), for
intramuscular use
Hemophilus influenza b vaccine (Hib), PRP-D conjugate, for booster use only,
intramuscular use
Hemophilus influenza b vaccine (Hib), PRP-OMP conjugate (3 dose schedule),
for intramuscular use

Vaccinations: Clinical Policy (Effective 10/01/2013)

1996-2013, Oxford Health Plans, LLC

CPT Code
90648
90649

90650*
90654
90655
90656
90657
90658
90660
90661
90662
90664
90666
90667
90668
90669
90670
90672
90675
90676
90680
90681
90685
90686
90696

90698
90700
90702
90703
90704
90705
90706
90707

Description
Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for
intramuscular use
Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3 dose
schedule, for intramuscular use
Note: Coverage is limited to patients age 9-26. Coverage ends on 27th birthday.
Human Papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose schedule,
for intramuscular use
Note: Coverage is limited to females age 9 - 26. Coverage ends on 27th birthday.
Influenza virus vaccine, split virus, preservative free, for intradermal use
Influenza virus vaccine, split virus, preservative free, when administered to
children 6-35 months of age, for intramuscular use
Influenza virus vaccine, trivalent, split virus, preservative free, when administered
to individuals 3 years and older, for intramuscular use
Influenza virus vaccine, trivalent, split virus, when administered to children 6-35
months of age, for intramuscular use
Influenza virus vaccine, trivalent, split virus, when administered to individuals 3
years of age and older, for intramuscular use
Influenza virus vaccine, trivalent, live, for intranasal use
Note: Coverage is limited to ages 2 - 49. Coverage ends on 50th birthday.
Influenza virus vaccine, derived from cell cultures, subunit, preservative and
antibiotic free, for intramuscular use
Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity
via increased antigen content, for intramuscular use
Note: Coverage is limited to ages 65+.
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
Pneumococcal conjugate vaccine, 7 valent, for intramuscular use
Pneumococcal conjugate vaccine, 13 valent, for intramuscular use
Influenza virus vaccine, quadrivalent, live, for intranasal use
Rabies vaccine, for intramuscular use
Rabies vaccine, for intradermal use
Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use
Rotavirus vaccine, human, attenuated, 2 dose schedule, live, for oral use
Influenza virus vaccine, quadrivalent, split virus, preservative free, when
administered to children 6-35 months of age, for intramuscular use
Influenza virus vaccine, quadrivalent, split virus, preservative free, when
administered to individuals 3 years of age and older, for intramuscular use
Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine,
inactivated (DTaP-IPV), when administered to children 4 years through 6 years of
age, for intramuscular use
Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza
Type B, and poliovirus vaccine, inactivated (DTaP - Hib - IPV), for intramuscular
use
Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when
administered to individuals younger than 7 years, for intramuscular use
Diphtheria and tetanus toxoids (DT) adsorbed when administered to individuals
younger than 7 years, for intramuscular use
Tetanus toxoid adsorbed, for intramuscular use
Mumps virus vaccine, live, for subcutaneous use
Measles virus vaccine, live, for subcutaneous use
Rubella virus vaccine, live, for subcutaneous use
Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use

Vaccinations: Clinical Policy (Effective 10/01/2013)

1996-2013, Oxford Health Plans, LLC

CPT Code
90708
90710
90712
90713
90714
90715
90716
90719
90720
90721
90723
90732
90733
90734
90736
90740
90743
90744
90746
90747
90748
90749
HCPCS
Code
Q2033
(effective
7/1/2013)
Q2034**
Q2035
Q2036
Q2037
Q2038
Q2039

Description
Measles and rubella virus vaccine, live, for subcutaneous use
Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous
use
Poliovirus vaccine, (any type[s]) (OPV), live, for oral use
Poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular use
Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, when
administered to individuals 7 years or older, for intramuscular use
Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when
administered to individuals 7 years or older, for intramuscular use
Varicella virus vaccine, live, for subcutaneous use
Diphtheria toxoid, for intramuscular use
Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and Hemophilus
influenza B vaccine (DTP-Hib), for intramuscular use
Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus
influenza B vaccine (DtaP-Hib), for intramuscular use
Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and
poliovirus vaccine, inactivated (DtaP-HepB-IPV), for intramuscular use
Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed
patient dosage, when administered to individuals 2 years or older, for
subcutaneous or intramuscular use
Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous use
Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent),
for intramuscular use
Zoster (shingles) vaccine, live, for subcutaneous injection
Note: Coverage for the Zoster vaccine is limited to age 60+
Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose
schedule), for intramuscular use
Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use
Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for
intramuscular use
Hepatitis B vaccine, adult dosage (3 dose schedule), for intramuscular use
Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose
schedule), for intramuscular use
Hepatitis B and Hemophilus influenza b vaccine (HepB-Hib), for intramuscular
use
Unlisted vaccine/toxoid
Description
Influenza vaccine, recombinant Hemagglutinin antigens for intramuscular use
(Flublok)
Influenza virus vaccine, split virus, for intramuscular use (Agriflu)
Influenza virus vaccine, split virus, when administered to individuals 3 years of
age and older, for intramuscular use (afluria)
Influenza virus vaccine, split virus, when administered to individuals 3 years of
age and older, for intramuscular use (flulaval)
Influenza virus vaccine, split virus, when administered to individuals 3 years of
age and older, for intramuscular use (fluvirin)
Influenza virus vaccine, split virus, when administered to individuals 3 years of
age and older, for intramuscular use (fluzone)
Influenza virus vaccine, split virus, when administered to individuals 3 years of
age and older, for intramuscular use (not otherwise specified)

CPT is a registered trademark of the American Medical Association.

*CPT 90650 is reimbursable for females only

**HCPCS Code Q2034 is effective for dates of service 07/01/2012 and after.
Vaccinations: Clinical Policy (Effective 10/01/2013)

1996-2013, Oxford Health Plans, LLC

Travel Vaccination Products

Non-Reimbursable CPT Codes
CPT Code
90690
90691
90692
90693
90717
90725
90727
90735
90738

Description
Typhoid vaccine, live, oral
Typhoid vaccine, Vi capsular polysaccharide (ViCPs), for intramuscular use
Typhoid vaccine, heat- and phenol-inactivated (H-P), for subcutaneous or
intradermal use
Typhoid vaccine, acetone-killed, dried (AKD), for subcutaneous use (U.S.
military)
Yellow fever vaccine, live, for subcutaneous use
Cholera vaccine for injectable use
Plague vaccine, for intramuscular use
Japanese encephalitis virus vaccine, for subcutaneous use
Japanese encephalitis virus vaccine, inactivated, for intramuscular use

CPT is a registered trademark of the American Medical Association.

Vaccination Products Pending FDA Approval

Non-Reimbursable CPT Codes
CPT Code
90644
90653
90687
90688
90739

Description
Meningococcal conjugate vaccine, serogroups C & Y and Hemophilus influenza B
vaccine (Hib-MenCY), 4 dose schedule, when administered to children 2-15
months of age, for intramuscular use
Influenza vaccine, inactivated, subunit, adjuvanted, for intramuscular use
Influenza virus vaccine, quadrivalent, split virus, when administered to children 635 months of age, for intramuscular use
Influenza virus vaccine, quadrivalent, split virus, when administered to individuals
3 years of age and older, for intramuscular use
Hepatitis B vaccine, adult dosage (2 dose schedule), for intramuscular use

CPT is a registered trademark of the American Medical Association.

REFERENCES
The foregoing Oxford policy has been adapted from an existing UnitedHealth Pharmaceutical
Solutions Clinical Pharmacy Program that was researched, developed and approved by the
UnitedHealthcare National Pharmacy & Therapeutics Committee. [2013D0031G]
1. Department of Health and Human Services. Centers for Disease Control and Prevention
(CDC). ACIP Recommendations. Available at http://www.cdc.gov/vaccines/pubs/ACIPlist.htm.
2. Department of Health and Human Services. Centers for Disease Control and Prevention
(CDC). How Vaccines Prevent Disease. Available at http://www.cdc.gov/vaccines/vacgen/howvpd.htm.
3. Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/default.htm.
Accessed March February 24, 2011.
4. American Medical Association. Current Procedural Terminology: CPT, Professional Edition.
5. Ingenix. Healthcare Common Procedure Coding System: HCPCS Level II Expert.
POLICY HISTORY/REVISION INFORMATION
Date

10/01/2013

Action/Description
Updated list of applicable (reimbursable) CPT codes for
vaccination products; added 90685 (previously listed as nonreimbursable/pending FDA approval)
Archived previous policy version VACCINES 005.37 T0

Vaccinations: Clinical Policy (Effective 10/01/2013)

1996-2013, Oxford Health Plans, LLC