Blue Cross Blue Shield RI Immunizations Coverage Update

Coverage rules, included codes, and exclusions

Coverage rules and exclusions

High-level coverage positions for Medicare Advantage and Commercial members, retail program participation, and common exclusions.

Medicare Advantage: Part B covers pneumococcal, influenza, hepatitis B for individuals at high or intermediate risk, and vaccines directly related to treatment of an injury or direct exposure (e.g., rabies). Other vaccines are covered under the member's Part D benefit.

Commercial Products: Vaccinations/immunizations are covered when recommended by CDC and AAP and when FDA guidelines are met.

State-supplied vaccines: Vaccines provided by the Rhode Island Department of Health are not reimbursed to providers by BCBSRI; providers should not bill for DOH-supplied biologicals.

Billing for provider‑supplied vaccine: For vaccines supplied by providers (non‑state‑supplied), submit the vaccine/toxoid procedure code and administration procedure code; indicate physician‑supplied vaccine pricing per billing guidance.

Travel‑related counseling and vaccines: Medicare Advantage does not cover vaccines related to travel (except via Part D); Commercial plans cover travel vaccines but travel clinic counseling (codes 99401–99404, 99411–99412) is typically not covered and members must be notified and may be billed directly (append GU or GX for Commercial when applicable).

School/employment immunizations: Immunizations required for school or employment or related to employment exposure are contract exclusions for both Medicare Advantage and Commercial products.

Vaccine Retail Program (Rhode Island pharmacies): Participating pharmacies may submit claims as specified — for Medicare Advantage: flu administration; shingles administration and supply; pneumococcal administration and supply. For Commercial: flu administration; shingles administration and supply (pneumococcal not included under retail program for Commercial).

Covered vaccine and administration codes

The following CPT/HCPCS vaccine and administration codes are identified as covered for Medicare Advantage Plans and/or Commercial products in the document excerpts provided.

Vaccine product codes (examples listed): 90611–90759 and Q2034–Q2038 (influenza HCPCS) are included among vaccine/toxoid codes covered as Part B benefit for specified vaccines (Medicare Advantage) or covered for Commercial when listed.

Immunization administration CPT codes covered: 90460, 90461, 90471, 90472, 90473, 90474. Use add‑on administration codes for multiple vaccines on the same date and indicate number of units.

Influenza HCPCS codes Q2034–Q2038 are listed for influenza products where applicable.

Unlisted vaccine codes Q2039 and 90749 are recognized; follow the unlisted procedures process for Medicare Advantage and Commercial products.

Separately reimbursed administration HCPCS/CPT for Medicare Advantage: G0010 (influenza administration), administration of pneumococcal vaccine, and administration of hepatitis B vaccine are noted as separately reimbursed.

Non-covered items

Exclusions / non-covered

Certain pandemic influenza formulations and RSV vaccine codes listed as non‑covered/contract exclusions while pending FDA approval: 90666–90668 and 90678.

Preventive counseling CPT codes (99401–99404, 99411–99412) are non‑covered when used for travel immunization counseling for Medicare Advantage and Commercial products; members should be notified and may be billed directly.

Diagnosis code pairings

Diagnosis code requirements for Medicare Part B coverage of certain vaccines

Rabies vaccine (when related to exposure/treatment): claim must include ICD‑10‑CM diagnosis code Z20.3 (Contact with and (suspected) exposure to rabies).

Hepatitis B vaccine coverage under Part B for individuals at high or intermediate risk requires ICD‑10‑CM code Z23 (Encounter for immunization) as applicable per the vaccine instructions.

Coverage notes

Coverage and billing stance for listed services

Preventive medicine counseling codes (99404, 99411, 99412) are referenced for counseling services; when used for travel counseling these codes are non‑covered and follow member notification/billing guidance.

Vaccine administration codes (including G0010 and other administration entries) are separately reimbursed for Medicare Advantage plans as noted; follow the Preventive Services for Medicare Advantage Plans policy for correct coding.

Unlisted vaccine/toxoid codes (Q2039, 90749) require following the unlisted procedures process for Medicare Advantage and Commercial products; providers may contact Part D plans about coverage for preventive vaccines not listed on a Part D formulary to facilitate reimbursement.

CPT/HCPCS codes, administration rules, and billing specifics

Covered CPT administration codesCPTCovered

90460	Immunization administration through 18 years of age; first vaccine/toxoid component; includes counseling by physician or other qualified health care professional.
90461	Immunization administration through 18 years of age; each additional vaccine/toxoid component (add-on).
90471	Immunization administration; one vaccine (single or combination vaccine/toxoid).
90472	Immunization administration; each additional vaccine (single or combination vaccine/toxoid) (add-on).
90473	Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid).
90474	Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (add-on).

Administration add-on and primary CPT codesCPTCovered

90461	Add-on: each additional vaccine/toxoid component (use units to indicate number of additional vaccines given same date by same provider).
90472	Add-on: each additional injectable vaccine/toxoid (use units to indicate number of additional vaccines given same date by same provider).
90474	Add-on: each additional intranasal/oral vaccine/toxoid (use units to indicate number of additional vaccines given same date by same provider).
90460	Primary code for immunization administration through age 18 with counseling — first vaccine/toxoid component.
90471	Primary code for one injectable vaccine administration (single or combination).
90473	Primary code for one intranasal/oral vaccine administration (single or combination).

Medicare Advantage: Covered vaccine product CPT/HCPCS codes (selected examples)mixedCovered

90611	Smallpox and monkeypox vaccine; attenuated vaccinia virus, non-replicating, 0.5 mL, subcutaneous; for patients 18 years and older.
90622	Vaccinia (smallpox) virus vaccine, lyophilized, 0.3 mL, percutaneous use.
90626	Tick-borne encephalitis virus vaccine, inactivated, 0.25 mL, intramuscular (effective 7/1/2022).
90627	Tick-borne encephalitis virus vaccine, inactivated, 0.5 mL, intramuscular (effective 7/1/2022).
90630	Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative-free, intradermal.
90653	Influenza virus vaccine, inactivated, subunit; adjuvanted, intramuscular.
90654	Influenza virus vaccine, trivalent (IIV3), split virus, preservative-free, intradermal.
90655	Influenza virus vaccine, trivalent (IIV3), split virus, preservative-free, 0.25 mL, intramuscular.

Commercial Products: Covered vaccine product CPT/HCPCS codes (selected examples)mixedCovered

90476	Adenovirus vaccine, type 4, oral, live.
90477	Adenovirus vaccine, type 7, oral, live.
90581	Anthrax vaccine; subcutaneous use.
90587	Smallpox and monkeypox vaccine, attenuated vaccinia virus, non-replicating, 0.5 mL, subcutaneous; for patients 18 years and older.
90619	Meningococcal conjugate vaccine, serogroups A,C,W,Y (MenACWY-TT), intramuscular.
90620	Meningococcal recombinant protein and OMV vaccine, serogroup B (MenB-4C), intramuscular.
90621	Meningococcal recombinant lipoprotein vaccine, serogroup B (MenB-FHbp), intramuscular.
90622	Vaccinia (smallpox) vaccine; live, lyophilized, percutaneous; for patients 12 months and older.

Non-covered / pending FDA approval (as applicable)CPTNot Covered

90666	Influenza virus vaccine (IIV), pandemic formulation, split virus, preservative-free, intramuscular — listed as non-covered/ pending FDA approval as applicable.
90667	Influenza virus vaccine (IIV), pandemic formulation, split virus, adjuvanted, intramuscular — listed as non-covered/ pending FDA approval as applicable.
90668	Influenza virus vaccine (IIV), pandemic formulation, split virus, intramuscular — listed as non-covered/ pending FDA approval as applicable.
90678	Respiratory syncytial virus (RSV) vaccine; subunit; bivalent; intramuscular — listed as non-covered/ pending FDA approval as applicable.

Preventive counseling and vaccine administration codes (non-covered for travel counseling)CPTCovered

90460	Immunization administration through 18 years with counseling — primary where applicable.
90461	Add-on immunization administration — additional vaccine/toxoid component with counseling.
90471	Immunization administration; one vaccine (injectable).
90472	Add-on immunization administration; each additional injectable vaccine.
90473	Immunization administration; one intranasal/oral vaccine.
90474	Add-on immunization administration; each additional intranasal/oral vaccine.

Billing guidance for multiple vaccines on same datemixed

	When multiple vaccines are administered on the same date by the same provider, file the appropriate administration add-on codes (90461, 90472, 90474) in addition to the primary administration code and indicate the number of units to reflect the number of additional vaccines provided.
	Report units for add-on codes to reflect each additional vaccine component; do not duplicate primary administration code units for each vaccine.

Prior authorization, billing process, and provider guidance

Prior Authorization

Prior Authorization: There is no prior authorization requirement for the vaccines and related preventive services described in this policy.

Billing Rule

Billing and Unlisted Procedures Guidance

Billing and unlisted procedures guidance: Use appropriate CPT/HCPCS vaccine administration and preventive counseling codes when billing. For Medicare Advantage Plans and Commercial products, certain vaccine products that do not have a specific HCPCS code must follow the plan’s unlisted procedures process. Specifically, Q2039 (Influenza virus vaccine, not otherwise specified) and 90749 (Unlisted vaccine/toxoid) require submission via the unlisted procedures process. Also ensure correct use of preventive medicine counseling codes (for example, 99401–99404 for individual counseling and 99411–99412 for group counseling) when counseling is billed separately. For Medicare Advantage claims, refer to the separate Preventive Services policy for correct coding of vaccine administration (including influenza and pneumococcal vaccines and administration of hepatitis B vaccine).

Definitions and key term clarifications

Medicare Part B vaccine coverage

Covered Part B vaccinesPneumococcal pneumonia vaccine is covered under Medicare Part B.

Influenza coverageInfluenza virus vaccine is covered under Medicare Part B.

Hepatitis B coverageHepatitis B vaccine is covered under Part B for individuals at high or intermediate risk.

Treatment-related vaccinesOther vaccines directly related to treatment of an injury or direct exposure (e.g., rabies, tetanus) are covered under Part B.

Medicare Part D vaccine coverage

Role of Part DMedicare Part D generally covers vaccines not reimbursed under Medicare Parts A or B when administration is reasonable and necessary.

OpenPayer

Immunizations Adult and Pediatric

Coverage rules, included codes, and exclusions

CPT/HCPCS codes, administration rules, and billing specifics

Prior authorization, billing process, and provider guidance

Definitions and key term clarifications