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The single best way to prevent the flu is to get vaccinated each season. There are two types of influenza vaccine: the injection and the nasal spray. Influenza viruses are always changing. Each year scientists try to match the viruses in the vaccine to those most likely to cause the flu that year. Yearly flu vaccination should begin in September, or as soon as vaccine is available, and continue throughout the flu season. . The timing and duration of flu seasons vary. Although the flu season can begin as early as October, most of the time seasonal flu activity peaks in January or later.

The influenza injection is an inactivated (killed) vaccine given into the muscle. It is indicated for use in people six months of age and older, including healthy people, people with chronic medical conditions, and pregnant women.

The nasal spray influenza vaccine is a vaccine made with live, attenuated (weakened) influenza viruses that do not cause the flu. The nasal spray flu vaccine is an option for healthy people who do not have an underlying medical condition that predisposes them to influenza complications and are not pregnant. Even people who live with or care for those in a high risk group can get the nasal spray flu vaccine as long as they are healthy themselves. The one exception is health care workers who care for people with severely weakened immune systems who require a protected hospital environment.

About two weeks after vaccination, antibodies develop that protect against influenza virus infection for approximately one year.

Inactivated influenza vaccine injection is not recommended for patients who have a history of hypersensitivity to egg proteins or other components of the vaccine, or life-threatening reaction to previous influenza vaccination.

Live attenuated influenza vaccine (FluMist®) or FluMist® Quadrivalent is indicated and considered medically necessary for active immunization of individuals 2-49 years of age against influenza disease caused by influenza virus subtypes A and type B contained in the vaccine.

Neither FluMist® nor FluMist® Quadrivalent is recommended for patients who are pregnant, immunocompromised, actively wheezing, less than 5 years of age and currently wheezing, have a history of Guillain-Barre syndrome within six weeks prior to any influenza vaccination, or have asthma or other underlying medical condition that predisposes them to influenza complications.

Children 2-8 years not previously vaccinated with influenza vaccine should receive 2 doses of FluMist® or FluMist® Quadrivalent (0.2mL each at least 1 month apart). Children 2-8 years previously vaccinated with influenza vaccine should receive 1 dose (0.2mL) of FluMist® or FluMist® Quadrivalent. Children, adolescents, and adults 9-49 years should also receive 1 dose (0.2mL) of FluMist® or FluMist® Quadrivalent. 

For children ages 0 – 18 years, all flu vaccines must be provided and administered in the provider’s office to be covered.  Flu vaccines for children ages 0 – 18 years are not covered when purchased or administered at a pharmacy.

FluMist® or FluMist® Quadrivalent must be provided and administered in the provider’s office to be covered. FluMist® and FluMist® Quadrivalent are not covered when purchased or administered at a pharmacy.

*Refer to the Prescribing Information of the specific vaccine to be administered (i.e. Fluzone, Afuria, Fluvirin) for the approved ages, dosage, and administration.

State Health Plan (State and School Employees)

12/30/2010:  The scope of the policy was expanded to include inactivated influenza vaccine.  Policy title changed from “Live Attenuated Influenza Vaccine (FluMist®)” to “Influenza Vaccine.” Policy statement updated to add information regarding the coverage of inactivated influenza vaccine. Policy statement updated to add the covered settings for vaccine administration. Added CPT codes 90655 – 90658 to the Code Reference section.

01/07/2013:  Added coverage guidelines for FluMist® Quadrivalent. Added the following new 2013 CPT code to the Code Reference section:  90672. 

Inactivated influenza virus vaccine Prescribing Information

FluMist® Quadrivalent Prescribing Information

Covered Codes

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document. 

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