CurrentmhnPolicy CP.PHAR.28

Immunization Coverage

Defines medical necessity and coverage criteria for childhood and adult immunizations for Medicaid members of health plans affiliated with Centene Corporation, including documentation requirements and exclusions for certain travel/military vaccines.

Policy Summary

Payermhn

PolicyImmunization Coverage

Policy CodePolicy CP.PHAR.28

Change TypeNo material change

Effective DateOct 1, 2008

Next Review Date

Key ActionProvider must submit documentation (office chart notes, lab results or other clinical information) showing the member meets all approval criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

ACIP-basedACIP alignment

VFCVFC referenced

ExcludedTravel/military exclusions

Per ACIPApproval duration

Coverage Criteria

Initial Approval Criteria

Covered when ALL of the following are met

Initial Approval for Childhood or Adult Immunization: There exists no product-specific clinical policy or custom coverage criteria.

Initial Approval for Childhood or Adult Immunization: Requested immunization will be given in accordance with the recommendations made by the Advisory Committee on Immunization Practices (ACIP).

Approval duration: Vaccine duration in accordance with ACIP recommendations

Initial Approval for Childhood or Adult Immunization: If the request is for a single antigen that is typically administered as part of a combination vaccine (e.g., measles, mumps, rubella, diphtheria, tetanus, pertussis), documentation supports medical necessity for administration of the single antigen.

Immunizations that are recommended specifically for travelers or for military personnel are not covered under this policy unless the vaccine is explicitly listed on the applicable state-specific preferred drug list (PDL). Examples of vaccines typically excluded unless found on the PDL include adenovirus, anthrax, Japanese encephalitis, smallpox (vaccinia), typhoid, and yellow fever. Coverage for any travel-related immunization will be authorized only when that vaccine appears on the state PDL.

Policy Summary

Payermhn

PolicyImmunization Coverage

Policy CodePolicy CP.PHAR.28

Change TypeNo material change

Effective DateOct 1, 2008

Next Review Date

Key ActionProvider must submit documentation (office chart notes, lab results or other clinical information) showing the member meets all approval criteria.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions & Requirements

Documentation Required

Required documentation & denial risk

Provider must submit documentation (such as office chart notes, lab results or other clinical information) supporting that member has met all approval criteria. Requests may be denied if required documentation is missing or incomplete.

Required documentation: office chart notes, lab results, other clinical information to support medical necessity
Approval duration: Vaccine duration in accordance with ACIP recommendations

Prior Authorization

Initial approval criteria

Initial approval requires that ALL provider-facing rules below are met. No product-specific clinical policy or custom coverage criteria apply here; immunizations must follow ACIP recommendations. If requesting a single-antigen vaccine when a combination vaccine is recommended, provide documentation justifying medical necessity for the single antigen.

No product-specific clinical policy or custom coverage criteria exist for the requested immunization
Requested immunization will be administered in accordance with ACIP recommendations (see Appendix D). Eligible VFC program immunizations should be provided by VFC
For single-antigen requests when combination vaccine is recommended, documentation must support medical necessity

Step Therapy

Step therapy

This policy does not specify any step therapy requirements for immunizations.

Denial Risk

Documentation and excluded indications

Requests for immunizations recommended for travelers or military personnel are not covered unless specifically listed on the state-specific preferred drug list (PDL). Examples of non‑covered travel/military immunizations include adenovirus, anthrax, Japanese encephalitis, smallpox (vaccinia), typhoid, and yellow fever.

Non-covered unless on state-specific PDL: adenovirus, anthrax, Japanese encephalitis, smallpox (vaccinia), typhoid, yellow fever
Coverage for travel immunizations listed on state-specific PDL are authorized

OpenPayer

Immunization Coverage

Coverage Criteria

Provider Actions & Requirements

Background

Definitions