Influenza Vaccines — CPB 0035 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0035 covering influenza vaccines, effective March 3, 2026. Here's what billing teams need to know about covered codes, age-based criteria, and the new H5N8 bird flu vaccine code.

Aetna's influenza vaccine coverage policy under CPB 0035 Aetna system now explicitly addresses avian influenza A (bird flu) vaccines alongside the standard seasonal flu lineup. The update adds CPT 90695 for the H5N8 cell-culture-derived influenza vaccine, and introduces two new mRNA influenza vaccine codes — CPT 90637 and CPT 90638 — to the covered code set. If your practice bills seasonal flu vaccines or participates in any expanded influenza vaccination programs, this policy touches your charge capture.

Quick-Reference Table

Aetna Influenza Vaccine Coverage Criteria and Medical Necessity Requirements 2026

Aetna's influenza vaccine coverage policy ties medical necessity directly to FDA approval status, patient age, and alignment with CDC ACIP recommendations. If the vaccine isn't FDA-approved and doesn't match the age criteria below, Aetna won't pay.

Here's how the age brackets break down for trivalent injectables:

For intranasal vaccines, the policy covers FluMist (CPT 90660 for trivalent LAIV3, CPT 90672 for quadrivalent LAIV4) for members aged 2 through 49. This is a defined window — not just a lower limit. Members outside that range are excluded.

FluMist carries specific restrictions. The CDC does not recommend it for pregnant patients, immunocompromised patients, or patients with asthma. Your ICD-10 documentation matters here. If a claim for CPT 90660 or CPT 90672 comes through with a diagnosis in the J45.20–J45.998 (asthma) range or the O00.101–O9A.519 (pregnancy) range, expect a claim denial. The policy flags those conditions explicitly.

Prior authorization requirements are not specified in this policy bulletin for standard seasonal influenza vaccines. These are preventive services with broad medical necessity coverage under ACIP-aligned criteria. That said, if you're billing combination codes like CPT 90612 or CPT 90613 — which pair influenza vaccine with a SARS-CoV-2 component — verify your reimbursement pathway before the patient leaves the office. Combination vaccine codes are newer and payer processing isn't always consistent.

The policy also covers quadrivalent formulations across multiple delivery formats: split virus preservative-free for intradermal use (CPT 90630), adjuvanted inactivated (CPT 90653, CPT 90694), cell-culture-derived (CPT 90674, CPT 90756), recombinant (CPT 90682), and mRNA formulations (CPT 90637 at 30 mcg/0.5 mL and CPT 90638 at 60 mcg/0.5 mL). The mRNA codes are new — flag them for your charge capture team now.

Aetna Influenza Vaccine Exclusions and Non-Covered Indications

One code is explicitly not covered: CPT 90664 — the live attenuated intranasal influenza vaccine in pandemic formulation. Aetna lists this in the CPB 0035 non-covered group. Don't bill it.

The avian influenza situation deserves a clear-eyed read. CPT 90695 — the H5N8 cell-culture-derived adjuvanted influenza vaccine — appears in the covered code set. But the policy notes that ACIP has not yet made a recommendation for H5N8 vaccination as of this update. No FDA-approved H5N1 (bird flu) vaccine is commercially available for the general population. The CDC considers the public health risk for H5 bird flu to be low as of May 2025, and stockpile vaccines exist under the federal NPIVS program, not commercial channels.

The real issue here: CPT 90695 is listed as covered if selection criteria are met, but no commercial patient population currently meets those criteria. This code exists for a scenario that hasn't arrived yet. Don't let it appear on routine claims.

Coverage Indications at a Glance

Aetna Influenza Vaccine Billing Guidelines and Action Items 2026

1. Add CPT 90637 and CPT 90638 to your charge capture before flu season prep begins.
These mRNA influenza vaccine codes are newly included in CPB 0035's covered set. If your EHR or chargemaster doesn't have them mapped, you'll create a billing gap. Do this now — not in October.

2. Confirm your FluMist age documentation before billing CPT 90660 or CPT 90672.
Aetna covers intranasal LAIV only for ages 2 through 49. Build an age check into your workflow. A 50-year-old patient getting FluMist is an automatic denial risk under this policy.

3. Flag ICD-10 diagnosis codes that contradict FluMist eligibility.
If a patient's chart includes J45.20–J45.998 (asthma), O00.101–O9A.519 (pregnancy codes), or a documented immunocompromised state, don't bill CPT 90660 or 90672. The policy specifically excludes these populations. Your billing team should screen for these codes at the time of service.

4. Do not bill CPT 90664 for Aetna patients.
This is a hard non-covered code in CPB 0035. The pandemic-formulation intranasal LAIV has no covered indication under this policy. Remove it from any Aetna-specific billing templates if it's currently included.

5. Hold CPT 90695 until ACIP issues an H5N8 recommendation.
Yes, the code is in the covered section. No, you shouldn't bill it now. The policy is explicit: ACIP has not made a recommendation for H5N8 vaccination. There is no commercially available H5N8 vaccine for the general public. Billing this code on a routine claim will trigger a denial and may create a compliance issue. Talk to your compliance officer before this code appears on any claim.

6. Verify reimbursement setup for combination flu + COVID codes CPT 90612 and CPT 90613.
These combination vaccine codes cover flu paired with a SARS-CoV-2 component. They're in the covered set, but payer adjudication for combination codes varies. Call Aetna provider services or check your remittance data from any prior claims before assuming these will process cleanly.

7. Use HCPCS G0008 for administration when appropriate.
When billing influenza vaccine administration for Aetna patients, G0008 (Administration of influenza virus vaccine) is in the covered HCPCS set. Pair it correctly with the vaccine code. Don't default to CPT 90471 if G0008 is the right code for your claim context.

8. Document age eligibility in the patient record for all age-bracketed vaccines.
Especially for Agriflu (Q2034, 18 years+), Flublok (CPT 90673, 9 years+), and the LAIV range (2–49 years). Aetna ties medical necessity to age. No documentation, no coverage.

CPT, HCPCS, and ICD-10 Codes for Influenza Vaccines Under CPB 0035

Covered CPT Codes (When Selection Criteria Are Met)

Not Covered CPT Codes

Covered HCPCS Codes (When Selection Criteria Are Met)

Key ICD-10-CM Diagnosis Codes