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May 2022

Blue Cross, BCN covering additional vaccines

To increase access to vaccines and decrease the risk of vaccine-preventable disease outbreaks, Blue Cross Blue Shield of Michigan and Blue Care Network will add the following vaccines to our list of vaccines covered under the pharmacy benefit:

Vaccine Common name and abbreviation Age requirement
Dengvaxia® Dengue vaccine None
Prevnar 20®

Pneumococcal — PCV20

None
Vaxneuvance™

Pneumococcal — PCV15

None

The following lists all the vaccines that are covered under eligible members’ prescription drug plans. Most Blue Cross and BCN commercial (non-Medicare) members with prescription drug coverage are eligible. If a member meets the coverage criteria, the vaccine is covered with no out-of-pocket costs.

Vaccine Common name and abbreviation Age requirement
Dengvaxia® Dengue vaccine None
Daptacel®

Diphtheria, tetanus and acellular pertussis vaccine — DTaP

None
Infanrix®

Diphtheria, tetanus and acellular pertussis vaccine — DTaP

None
Diphtheria and Tetanus Toxoids Diphtheria, tetanus vaccine — DT None
Kinrix®

DTaP and inactivated poliovirus vaccine — DTaP-IPV

None
Quadracel®

DTaP and inactivated poliovirus vaccine — DTaP-IPV

None
Pediarix® DTaP, hepatitis B and inactivated poliovirus vaccine — DTaP-HepB-IPV None
Pentacel®

DTaP, inactivated poliovirus and Haemophilus influenzae type b vaccine — DTaP-IPV/Hib

None
Vaxelis®

DTaP, inactivated poliovirus, Haemophilus influenzae type b and hepatitis B vaccine — DTaP-IPV-Hib-HepB)

None
ActHIB® Haemophilus influenzae type b vaccine — Hib None
Hiberix®

Haemophilus influenzae type b vaccine — Hib

None
PedvaxHIB®

Haemophilus influenzae type b vaccine — Hib

None
Havrix® Hepatitis A — HepA None
Vaqta®

Hepatitis A — HepA

None
Engerix-B®

Hepatitis B — HepB

None
Heplisav-B® Hepatitis B — HepB None
Recombivax HB®

Hepatitis B — HepB

None
Twinrix®

Hepatitis A & B — HepA-HepB

None
Gardasil 9® Human papillomavirus vaccine 9 to 45 years old
Influenza virus

Influenza, or flu, vaccine

Under 9: 2 vaccines per 180 days

9 and older: 1 vaccine per 180 days
M-M-R II®

Measles, mumps, rubella vaccine — MMR

None
ProQuad® Measles, mumps, rubella and varicella vaccine — MMRV None
Menveo®

Meningococcal serogroups A, C, W, Y vaccine — MenACWY-CRM

None
Menactra®

Meningococcal serogroups A, C, W, Y vaccine — MenACWY-D

None
MenQuadfi® Meningococcal serogroups A, C, W, Y vaccine — MenACWY-TT None
Bexsero®

Meningococcal serogroup B vaccine — MenB-4C

None
Trumenba®

Meningococcal serogroup B vaccine — MenB-FHbp

None
Prevnar 13®

Pneumococcal 13-valent conjugate vaccine — PCV13

65 and older
Vaxneuvance™

Pneumococcal 15-valent conjugate vaccine — PCV15

None
Prevnar 20™

Pneumococcal 20-valent conjugate vaccine — PCV20

None
Pneumovax 23®

Pneumococcal 23-valent polysaccharide vaccine — PPSV23

None
IPOL®

Poliovirus vaccine — IPV

None
Rotarix®

Rotavirus vaccine — RV1

None
RotaTeq® Rotavirus vaccine — RV5 None
Tdvax™

Tetanus and diphtheria vaccine — Td

None
Tenivac®

Tetanus and diphtheria vaccine — Td

None
Adacel®

Tetanus, diphtheria and acellular pertussis vaccine — Tdap

None
Boostrix®

Tetanus, diphtheria and acellular pertussis vaccine — Tdap

None
Varivax®

Varicella vaccine — VAR or chickenpox

None
Shingrix®

Zoster vaccine — RZV or shingles

None

If a member doesn’t meet the age requirement for a vaccine, Blue Cross and BCN won’t cover the vaccine under the prescription drug plan and the claim will reject.

Vaccines must be administered by certified, trained and qualified registered pharmacists.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2021 American Medical Association. All rights reserved.