CommercialCoverageMedium impact
Influenza Vaccines (CPB 0035, reviewed 2026-10-08)
Aetna·Allergy & Immunology, Family Medicine, General Practice +3 more·Medical Policy
We identified it
Oct 10, 2026
Summary
Aetna's Clinical Policy Bulletin 0035 on influenza vaccines (reviewed 2026-10-08) establishes medical necessity criteria for FDA-approved influenza vaccines across multiple formulations and age groups, including standard trivalent injectables, mRNA vaccines, intranasal vaccines, and H5N1 avian influenza vaccines for high-risk populations. The policy provides specific CPT and HCPCS billing codes for covered vaccine types and administration, with age-based restrictions and clinical notes on contraindications.
Action Required
Billing team should verify current applicability of this policy by confirming: (1) Whether Aetna's influenza vaccine coverage criteria have been implemented in the billing system, including age-based restrictions (e.g., mRNA vaccines for members 50+ years, intranasal FluMist for ages 2–49); (2) Whether the listed CPT codes (90612–90695, 90660, 90672 for intranasal; 90655–90658, 90685–90688 for standard injectables; 90662, 90694 for high-dose/adjuvanted for 65+) are configured for correct billing; (3) Whether clinical notes regarding contraindications (pregnancy, immunocompromise, asthma) are documented to support medical necessity if audited; (4) Whether H5N1 vaccine claims (CPT 90695) are restricted to members at increased risk of exposure per CDC guidance, not general population. No source-stated future deadline or effective date is provided; retain this guidance as the current standard for Aetna beneficiaries.