Diphtheria, Tetanus, and Pertussis Vaccines — CPB 0653 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0653 governing diphtheria, tetanus, and pertussis vaccine coverage, effective December 9, 2025. Here's what billing teams need to know before the next immunization claim goes out the door.

This update to the Aetna diphtheria, tetanus, and pertussis vaccine coverage policy touches CPT codes 90700, 90715, 90723, 90696, 90697, 90698, 90702, 90714, 90471, and 90472. CPB 0653 Aetna system governs medical necessity criteria for the full DTaP, Tdap, and combination vaccine series across pediatric and adult populations. If your practice bills vaccines for any age group — from two-month-old infants to adults 65 and older — this policy sets the rules for what gets paid.

Quick-Reference Table

Aetna DTaP and Tdap Vaccine Coverage Criteria and Medical Necessity Requirements 2025

The real issue with vaccine billing isn't whether vaccines are covered — they almost always are. The issue is that Aetna's coverage policy is brand-specific and age-specific, and a single mismatch between the vaccine you administered and the criteria tied to that CPT code will produce a claim denial.

Start with the basics. Aetna covers DTaP and Tdap vaccines as preventive services when administered according to ACIP recommendations. That's the foundation. Everything else in CPB 0653 is a layer of specificity on top of that baseline.

Pediatric Combination Vaccines

Pediarix (GSK) — billed as CPT 90723, covering DTaP, hepatitis B, and inactivated poliovirus — meets medical necessity as an alternative to individual vaccines at two months, four months, and six months of age. This is a three-dose series. If your practice uses Pediarix outside those age windows or beyond three doses, Aetna won't cover it under this policy.

Pentacel (Sanofi Pasteur) maps to CPT 90698. It covers DTaP, inactivated poliovirus, and Haemophilus influenzae type b. Aetna covers it in children six weeks through four years of age — specifically, prior to age five — as a four-dose series at two months, four months, six months, and 15 to 18 months.

Vaxelis (Sanofi Pasteur) maps to CPT 90697. This combination adds hepatitis B to the Pentacel mix. Aetna covers it in the same age range — six weeks through four years — but as a three-dose series at two months, four months, and six months only. Don't confuse the dose count with Pentacel. They cover different components and follow different schedules.

Kinrix (GSK) and Quadracel (Sanofi Pasteur) both cover the fifth DTaP dose in children four through six years of age. Both map to CPT 90696. The difference: Kinrix is only covered when the child's prior DTaP doses used Infanrix and/or Pediarix for doses one through three, and Infanrix for dose four. Quadracel requires prior doses using Pentacel and/or Daptacel. This is where brand continuity matters. If the prior dose history doesn't match, Aetna's medical necessity criteria aren't satisfied.

Adult and Adolescent Tdap Vaccines

Boostrix (GSK) covers individuals 10 years and older — no upper age limit. Adacel (Sanofi Pasteur) covers individuals 10 through 64 years only. Both bill under CPT 90715. Know which brand you're using. Billing Adacel for a 65-year-old doesn't meet Aetna's criteria. Boostrix does.

For adults 65 and older, Aetna covers Tdap as a preventive service regardless of prior vaccination history. The policy is clear on this. There's no requirement to show the patient hasn't received Tdap before. Same rule applies to pregnant women — Tdap is covered regardless of vaccination history. Women who weren't vaccinated during pregnancy can receive it immediately postpartum.

Children seven through ten years with incomplete or unknown pertussis vaccine history also qualify for a single Tdap dose under this coverage policy.

Wound Management

CPT 90702 (DT for children under seven) and CPT 90714 (preservative-free Td, Tenivac) are both covered for contaminated wound management. The ICD-10 diagnosis codes tied to wound indications are extensive — open wounds, fractures, burns, dislocations — and your clinical documentation needs to support the wound classification billed. We'll cover the full code list below.

Prior authorization is not called out as a requirement for these vaccines in CPB 0653, consistent with how preventive vaccine services generally move through Aetna's system. That said, verify at the plan level. Some self-funded plans carve out preventive services differently, and prior auth requirements can vary.

Coverage Indications at a Glance

Aetna DTaP and Tdap Vaccine Billing Guidelines and Action Items 2025

The effective date of December 9, 2025 is your target. Any claim for these vaccines submitted on or after that date needs to reflect the criteria in the updated CPB 0653.

If your practice has unusual vaccine brand substitutions or you operate in a specialty setting where these indications get complicated, loop in your compliance officer before December 9, 2025.

CPT, HCPCS, and ICD-10 Codes for DTaP and Tdap Vaccines Under CPB 0653

Covered CPT Codes (When Selection Criteria Are Met)

Key ICD-10-CM Diagnosis Codes

A note on the wound and fracture codes: every open fracture and dislocation code requiring a companion open wound code needs that pairing on the claim. Submitting the fracture code alone without the corresponding open wound code is a clean path to a claim denial on wound-related vaccine reimbursement.