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L.2.01.402
Afluria(influenza vaccine)Fluad (influenza vaccine, adjuvanted)Fluarix(influenza vaccine)Flublok(influenza vaccine)Flucelvax(influenza vaccine)Flulaval(influenza vaccine)FluMist(influenza vaccine live, intranasal)Fluzone High-Dose(influenza vaccine)Fluzone(influenza vaccine)
Please perform a formulary drug search on your patient’s member ID to ensure the prescription drug is covered under their benefit plan. The medication(s) in this medical policy may not be covered under a specific member’s benefit plan.
Influenza, commonly known as the flu, is a contagious respiratory illness caused by influenza viruses. It can cause mild to severe illness, and at times can lead to death. Complications of flu can include bacterial pneumonia, ear infections, sinus infections, dehydration, and worsening of chronic medical conditions.
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 the 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 2 to 49 years of age. It is not recommended for use in pregnant women, immunocompromised people, or people with certain medical conditions.
About two weeks after vaccination, antibodies develop that protect against influenza virus infection for approximately one year.
Inactivated Influenza Vaccines:
Inactivated influenza vaccine injection is indicated and considered medically necessary for active immunization of individuals *6 months of age and older against influenza disease caused by influenza virus subtypes A and type B contained in the vaccine.
Most inactivated influenza vaccine injections are not recommended for patients who have a history of severe allergic reactions (e.g., anaphylaxis) to egg proteins or other components of the vaccine, or life-threatening reaction to previous influenza vaccination. Flublok and Flucelvax are available for patients with a hypersensitivity to eggs.
Effective 10/23/15: For children ages 0 – 11 years, all flu vaccines must be provided and administered in the provider’s office to be covered. Flu vaccines for children ages 0 – 11 years 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, Afluria, Fluvirin) for the approved ages, dosage, and administration.
Live Attenuated Influenza Vaccines:
Live attenuated influenza vaccine (FluMist) 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.
FluMist is not recommended for patients who are pregnant, immunocompromised, actively wheezing, less than 5 years of age with recurrent 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 (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. Children, adolescents, and adults 9-49 years should also receive 1 dose (0.2mL) of FluMist.
FluMist must be provided and administered in the provider’s office to be covered. FluMist is not covered when purchased or administered at a pharmacy.
State Health Plan (State and School Employees): The prescription drug(s) in this medical policy may be covered under a prescription drug benefit plan administered by the State Health Plan’s Pharmacy Benefit Manager. Please perform a formulary drug search at https://www.dfa.ms.gov/cvs-caremark and submit any required Prior Authorization Requests for coverage determination to the Plan’s Pharmacy Benefit Manager. Services related to delivery and/or administration of a medication determined to be not medically necessary will also be considered not medically necessary. Services related to delivery and/or administration of a self-administered drug are not covered.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
12/01/2010: Policy added.
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.
02/20/2014: Removed CPT codes from Code Reference section and provided the link to the Healthy You! Wellness Procedures Coding Guidelines.
07/30/2015: Code Reference section updated for ICD-10.
12/01/2015: Policy section updated to state that effective 10/23/15, for children ages 0-11 years, all flu vaccines must be provided and administered in the provider's office to be covered. Flu vaccines for children ages 0-11 years are not covered when purchased or administered at a pharmacy. The previous age range was "0-18 years." Policy guidelines updated to add medically necessary and investigational definitions.
06/06/2016: Policy number L.2.01.402 added.
08/09/2016: Approved by Pharmacy & Therapeutics (P&T) Committee.
02/07/2017: Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee.
02/06/2018: Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee.
02/05/2019: Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee. Added statement to perform a formulary drug search on the patient's member ID to ensure the prescription drug is covered under their benefit plan. The medication(s) in this medical policy may not be covered under a specific member's benefit plan. Policy section updated to add headings for inactivated influenza vaccines and live attenuated influenza vaccines. Effective 01/01/2019.
07/31/2020: Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee. Sources updated.
07/13/2021: Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee. Added drug names to the top of the policy. Updated policy statement regarding inactivated influenza vaccine injections. Policy Exceptions updated. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity." Removed investigative definition. Sources updated.
02/01/2023: Policy Exceptions updated to add the following: State Health Plan (State and School Employees): The prescription drug(s) in this medical policy may be covered under a prescription drug benefit plan administered by the State Health Plan’s Pharmacy Benefit Manager. Please perform a formulary drug search at https://www.dfa.ms.gov/cvs-caremark and submit any required Prior Authorization Requests for coverage determination to the Plan’s Pharmacy Benefit Manager. Services related to delivery and/or administration of a medication determined to be not medically necessary will also be considered not medically necessary. Services related to delivery and/or administration of a self-administered drug are not covered.
10/01/2024: Policy reviewed and approved by the Pharmacy & Therapeutics (P&T) Committee. Updated drug names and added Fluzone Trivalent. Policy statements unchanged. Sources updated.
09/09/2025: Policy reviewed and approved by the Pharmacy & Therapeutics (P&T) Committee. Policy updated to remove Fluzone Trivalent from the list of drugs. Policy description updated regarding the nasal spray flu vaccine. Policy statements for live attenuated influenza vaccines updated to remove FluMist Quadrivalent. Sources updated.
Afluria prescribing information. Seqirus Pty Ltd. June 2025. Last accessed July 2025.
Clinical Guidance for Influenza Vaccination.
Fluad prescribing information. Seqirus, Inc. July 2025. Last accessed July 2025.
Fluarix prescribing information. GlaxoSmithKline Biologicals. July 2025. Last accessed July 2025.
Flublok prescribing information. Sanofi Pasteur Inc. July 2025. Last accessed July 2025.
Flucelvax prescribing information. Seqirus Inc. July 2025. Last accessed July 2025.
Flulaval prescribing information. ID Biomedical Corporation of Quebec. July 2025. Last accessed July 2025.
FluMist prescribing information. MedImmune, LLC. August 2024. Last accessed July 2025.
Fluzone High-Dose prescribing information. Sanofi Pasteur Inc. July 2025. Last accessed July 2025.
Fluzone prescribing information. Sanofi Pasteur Inc. July 2025. Last accessed July 2025.
Influenza Vaccine Composition for the 2025-2026 U.S. Influenza Season. U.S. Food and Drug Administration. https://www.fda.gov/vaccines-blood-biologics/influenza-vaccine-composition-2025-2026-us-influenza-season . Last accessed July 2025.
U.S. Centers for Disease Control and Prevention. https://www.cdc.gov/flu/hcp/vax-summary/index.html . Last accessed July 2025.
Use of Trivalent Influenza Vaccines for the 2024-2025 U.S. Influenza Season. https://www.fda.gov/vaccines-blood-biologics/lot-release/use-trivalent-influenza-vaccines-2024-2025-us-influenza-season
Covered Codes
Code Number | Description |
CPT-4 | |
HCPCS | |
ICD-10 Procedure | |
ICD-10 Diagnosis |
CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.