Medical Policy

This document addresses the use of childhood and adult immunizations as recommended by the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), and the Advisory Committee on Immunization Practices (ACIP) for the Centers for Disease Control and Prevention (CDC). Immunization is a technique used to induce immune resistance to a specific disease in humans by exposing the individual to an antigen in order to raise antibodies to that antigen. This process increases an individual’s reaction to an antigen and therefore improves the ability to resist or overcome infection. Current immunization schedules and recommendations can be found at the following websites:

• American Academy of Family Physicians: https://www.aafp.org/family-physician/patient-care/prevention-wellness/immunizations-vaccines.html
• American Academy of Pediatrics: https://www.aap.org/en/patient-care/immunizations/
• Advisory Committee on Immunization Practices: https://www.cdc.gov/vaccines/?CDC_AAref_Val=https://www.cdc.gov/vaccines/schedules/

Note: For a high-level overview of this document, please see “Summary for Members and Families” below. 

Medically Necessary:

For Childhood Immunizations:

The most recent recommendations of the American Academy of Family Physicians (AAFP), or the American Academy of Pediatrics (AAP), or the affirmative recommendations of the Advisory Committee on Immunization Practices (ACIP) for the Centers for Disease Control and Prevention (CDC) for childhood immunizations are considered medically necessary.

For Adult Immunizations:

The most recent recommendations of the American Academy of Family Physicians (AAFP) or affirmative recommendations of the Advisory Committee on Immunization Practices (ACIP) for the Centers for Disease Control and Prevention (CDC) for adult immunizations are considered medically necessary.

Not Medically Necessary:

Childhood and adult immunizations are considered not medically necessary for all other indications not listed above.

Note: Permissive recommendations of the Advisory Committee on Immunization Practices (ACIP) for the Centers for Disease Control and Prevention (CDC) for childhood and adult immunizations are reviewed on an individual basis to determine medical necessity and will be listed in the position statement of this document when determined to be not medically necessary.

This document describes clinical studies and expert recommendations, and explains whether childhood and adult immunizations are appropriate. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

Immunization is a way to help the body build protection against serious diseases. It works by exposing the body to a small part of a virus or bacteria, called an antigen, which helps the immune system make new proteins called antibodies to fight infections by that antigen in the future. Experts in children’s and adult health recommend routine immunizations for people of all ages. Vaccines may be given as shots or oral drops, and are given at different times in life, starting from infancy. Some vaccines are for everyone, while others are only for people with certain health risks or those traveling to certain areas. While some vaccines are recommended for everyone, like the flu shot, others depend on a person’s age, health, or health, job, or lifestyle risk factors. All vaccines listed here have been reviewed by major health organizations and are supported by strong expert agreement.

What the Studies Show

Studies show that vaccines are among the safest and most effective ways to prevent disease. Medical and public health experts in the U.S. and around the world agree that the benefits of vaccination far outweigh any risks. Routine immunization programs, starting in infancy and continuing into adulthood, help protect people and communities from dangerous diseases. New vaccines continue to be developed and studied, such as those for respiratory syncytial virus (RSV) and mpox (previously called monkey pox), and updates to existing vaccines aim to improve protection. Expert groups carefully review data before recommending vaccines. They consider how well a vaccine works, how safe it is, and which groups of people would benefit most.

Vaccination recommendations are grouped into three types:

1. Routine vaccines are given to everyone in a certain age group.
2. Catch-up vaccines help people who missed earlier doses.
3. Risk-based vaccines are for people with specific health conditions or risks.

(Return to Description/Scope)

Immunizations are among the safest and most effective medicines. The overwhelming majority of medical experts in the United States and abroad believe that the benefits of complete immunization far outweigh the risks. Global health experts are in full accord with the concept that everyone who is healthy should be immunized as recommended.

ACIP, a United States federal advisory committee, provides guidance to the Secretary and the Assistant Secretary for Health and Human Services and the Director of the CDC regarding vaccines and related agents for control of vaccine-preventable diseases within the United States. Following the Omnibus Budget Reconciliation Act of 1993, ACIP assumed the role of developing a list of vaccines for administration to children eligible to receive vaccines through the Vaccines for Children (VFC) Program, along with schedules regarding correct dosages, dosing intervals, and contraindications applicable to pediatric vaccines. VFC resolutions passed by ACIP form the basis for VFC program policies on vaccine availability and usage.

Recommendations developed by ACIP may be either affirmative, permissive or shared clinical decision-making recommendations. Affirmative recommendations are characterized as routine, catch-up, and risk-based. Routine vaccinations are most commonly implemented for a specific age group; catch-up vaccinations are usually for defined periods of time and cohorts; and risk-based recommendations are typically those for a high-risk population. A permissive recommendation is issued to reflect situations where vaccination may be effective, but ACIP is not recommending routine use. Shared clinical decision-making recommendations represent a paradigm shift; recommendations are not targeted to a specific population (such as a specific age group or risk category), but are based upon an informed conversation between the individual and their provider. The key distinction between shared clinical decision-making and the previous categories is outlined on the CDC website noting:

The key distinction between routine, catch-up, and risk-based recommendations and shared clinical decision-making recommendations is the default decision to vaccinate. For routine, catch-up, and risk-based recommendations, the default decision should be to vaccinate the patient based on age group or other indication, unless contraindicated. For shared clinical decision-making recommendations, there is no default- the decision about whether or not to vaccinate may be informed by the best available evidence of who may benefit from vaccination; the individual’s characteristics, values, and preferences; the health care provider’s clinical discretion; and the characteristics of the vaccine being considered. There is not a prescribed set of considerations or decision points in the decision-making process.

Ongoing ACIP recommendations continue to expand the evidence base for immunization, incorporating new vaccines such as higher-valent pneumococcal conjugates, respiratory syncytial virus (RSV) vaccines, and catch-up schedules for diseases like polio, as well as refined schedules for meningococcal protection, reinforcing the safety and efficacy of comprehensive vaccination programs.

Table Abbreviations:

AAFP: American Academy of Family Physicians; AAP: American Academy of Pediatrics; AC: Advisory Committee; ACC: American College of Cardiology; ACIP: Advisory Committee on Immunization Practices; ACOG: American College of Obstetricians and Gynecologists; ADA: American Diabetes Association; AHA: American Heart Association; Centers for Disease Control and Prevention; DEN4CYD: Dengue tetravalent vaccine, live attenuated (CYD-TDV); DTaP: Diphtheria, tetanus, and acellular pertussis; HepA: Hepatitis A vaccine; HepB: Hepatitis B vaccine; Hib: Haemophilus influenzae type b vaccine; HBIG: Hepatitis B immune globulin. HPV: Human papillomavirus vaccine; IDSA: Infectious Diseases Society of America; IPV: Inactivated poliovirus vaccine; ISDA: Infectious Diseases Society of America (duplicate abbreviation standardized as IDSA); JYNNEOS: Mpox (monkeypox) vaccine, live, non-replicating; MenACWY: Meningococcal conjugate vaccine (serogroups A, C, W, and Y); MenB: Meningococcal serogroup B vaccine; MMR: Measles, mumps, and rubella vaccine; MMRV: Measles, mumps, rubella, and varicella vaccine; PCV: Pneumococcal conjugate vaccine; PPSV23: Pneumococcal polysaccharide vaccine (23-valent); RIV3: Recombinant influenza vaccine, trivalent; RSV: Respiratory syncytial virus; RZV: Recombinant zoster vaccine; Td: Tetanus and diphtheria toxoids; Tdap: Tetanus, diphtheria, and acellular pertussis (adult formulation); VAR: Varicella vaccine.

Table Abbreviations:

ACAM2000: Smallpox and orthopoxvirus vaccine, live; ACIP: Advisory Committee on Immunization Practices; BioThrax: Anthrax vaccine adsorbed; CDC: Centers for Disease Control and Prevention; Cyfendus: Anthrax vaccine adjuvanted for post-exposure prophylaxis; DoD: Department of Defense; Ervebo: Ebola Zaire vaccine, recombinant; Imovax Rabies: Rabies vaccine (human diploid cell); IXIARO: Japanese encephalitis vaccine, inactivated, Vero cell; JE: Japanese encephalitis; PEP: Post-exposure prophylaxis; PrEP: Pre-exposure prophylaxis; RabAvert: Rabies vaccine (purified chick embryo cell); S. Typhi: Salmonella enterica serovar Typhi; TBE: Tick-borne encephalitis; TicoVac: Tick-borne encephalitis vaccine; Vaxchora: Cholera vaccine, live oral; VIMKUNYA: Chikungunya virus recombinant virus-like particle vaccine; Vivotif: Typhoid vaccine, live oral; YF-VAX: Yellow fever vaccine, live.

Immunization is the process of inducing or providing immunity artificially by administering an immunobiologic. Immunization can be active or passive. Active immunization is the production of antibody or other immune responses through the administration of a vaccine or toxoid. Passive immunization means the provision of temporary immunity by the administration of preformed antibodies. Recommendations for vaccinating infants, children, and adults are based on characteristics of immunobiologics, scientific knowledge about the principles of active and passive immunization and the epidemiology of diseases, and judgments by public health officials and specialists in clinical and preventive medicine. Immunization programs help build defenses against disease and should be started early and carried out on a regular and routine basis.

Childhood immunizations consist of a series of intramuscular injections, subcutaneous injections, or oral dosing of inactivated bacteria, toxoids, live attenuated viruses, or inactive viral antigens against several diseases: diphtheria, tetanus, pertussis, measles, mumps, rubella, polio, Haemophilus influenzae type b, human papilloma virus (HPV), hepatitis A, hepatitis B, influenza, varicella, pneumococcus and rotavirus. Many of the immunizations are given as combined vaccines during routine well-child checks in the first 2 years of life. Immunizations against diseases for which risk factors are related to adolescent issues are recommended at ages prior to when exposure most frequently occurs. These include meningitis, hepatitis B, and HPV.

Most adult immunizations are administered in primary series (in previously unimmunized persons), booster doses, and periodic doses. Agents include toxoids (diphtheria and tetanus), live virus vaccines (measles, mumps, and rubella), influenza (including trivalent formulations), inactive viral particles (hepatitis B), highly purified virus-like particles (HPV), inactivated bacterial polysaccharide and conjugate vaccines (pneumococcal, including higher-valent options like PCV21), inactivated vaccines (polio for incomplete vaccination), and mRNA or protein-based vaccines (for example for respiratory syncytial virus [RSV]).

Vaccines using a non-viral vector or messenger RNA (mRNA) delivered via a nucleic acid-based agent are the most recent technology publicly available. The mRNA technique delivers a transcript which encodes one or more immunogens into the host cell, and subsequent translation generates immunogenic proteins. The advantage of using mRNA vaccines is the ability to develop and produce large quantities of vaccines in a shorter period of time.

Recommended immunization schedules are grouped by types of vaccine and the recipient’s age. Certain vaccinations are present on both childhood and adult schedules, while others may be limited to a specific schedule. ACIP provides the following recommendations:

• Age specific: https://www.cdc.gov/vaccines/schedules.
• Vaccine-specific: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/index.html.

For criteria related to specific immunizations, such as palivizumab, refer to applicable guidelines used by the plan.

Antibody: A type of protein produced by the immune system in response to foreign substances that may be a threat to the body such as chemicals, virus particles, spores, or bacterial toxins. These foreign substances are called antigens. Each type of antibody is unique and defends the body against one specific type of antigen.

Antigen: Any substance that, when introduced into the body, evokes an immune response and stimulates the production of antibodies.

Attenuated vaccine: A vaccine using a weakened virus to stimulate an immune response. The virus can be weakened using chemical or physical processes.

mRNA vaccine: A vaccine using messenger RNA (mRNA) to prompt cells to produce an immunogenic protein, triggering an immune response; widely used for diseases like COVID-19 and respiratory syncytial virus (RSV).

Coding edits for medical necessity review are not implemented for this administrative policy. Where a more specific policy or guideline exists, that document will take precedence and may include specific coding edits and/or instructions. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Peer Reviewed Publications:

1. Kowalzik F, Schreiner D, Jensen C, et al. mRNA-Based Vaccines. Vaccines (Basel). 2021; 9(4):390.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Academy of Family Physicians. Immunization schedules. 2025. Available at: https://www.aafp.org/family-physician/patient-care/prevention-wellness/immunizations-vaccines/immunization-schedules.html. Accessed on December 18, 2025.
2. American Academy of Pediatrics. Immunization schedules. November 21, 2025. Available at: https://publications.aap.org/redbook/resources/15585/. Accessed on December 18, 2025.
3. American College of Obstetricians and Gynecologists. Maternal immunization. Reaffirmed 2021. Available at: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/06/maternal-immunization. Accessed December 18, 2025.
4. American College of Obstetricians and Gynecologists. Influenza in pregnancy: prevention and treatment. ACOG Practice Advisory. October 2025. Available at: https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2025/08/influenza-in-pregnancy-prevention-and-treatment. Accessed December 18, 2025.
5. American College of Obstetricians and Gynecologists. Management of obstetric-gynecologic patients during a measles outbreak. Last updated May 16, 2025. Available at: https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2024/03/management-of-obstetric-gynecologic-patients-during-a-measles-outbreak. Accessed December 18, 2025.
6. American Diabetes Association Professional Practice Committee. 4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Care in Diabetes 2025. Diabetes Care. 2025; 48(Suppl 1):S59-S85.
7. American College of Obstetricians and Gynecologists. Viral hepatitis in pregnancy: ACOG clinical practice guideline No. 6. Obstet Gynecol. 2023; 142(3):745-759.
8. Centers for Disease Control and Prevention. ACIP Shared Clinical Decision-Making Recommendations. January 7, 2025. Available at: https://www.cdc.gov/acip/vaccine-recommendations/shared-clinical-decision-making.html. Accessed on December 18, 2025.
9. Centers for Disease Control and Prevention. Heplisav-B^® (HepB-CpG) Vaccine. Available at: https://www.cdc.gov/vaccines/?CDC_AAref_Val=https://www.cdc.gov/vaccines/schedules/vacc-updates/heplisav-b.html. Accessed on December 18, 2025.
10. Centers for Disease Control and Prevention. Prevention and control of seasonal influenza with vaccines: Recommendations of the Advisory Committee on Immunization Practices, United States, 2024 to 25 Influenza Season. August 29, 2024. Available at: https://www.cdc.gov/mmwr/volumes/73/rr/rr7305a1.htm. Accessed on December 182025.
11. Centers for Disease Control and Prevention. Vaccines in the Adult Immunization Schedule. October 7, 2025. Available at: https://www.cdc.gov/vaccines/hcp/imz-schedules/adult-schedule-vaccines.html. Accessed on December 18, 2025.
12. Centers for Disease Control and Prevention. Child and Adolescent Immunization Schedule by Age (Addendum updated August 7, 2025). Available at: https://www.cdc.gov/vaccines/hcp/imz-schedules/child-adolescent-age.html. Accessed on December 18, 2025.
13. Department of Health and Human Services. Affordable Care Act. Coverage of Preventive Health Services.
    • 26 CFR 54.9815-2713(a)(1)(ii). Available at: https://www.govinfo.gov/content/pkg/CFR-2020-title26-vol19/pdf/CFR-2020-title26-vol19-sec54-9815-2713A.pdf. Accessed on December 18, 2025.
    • 29 CFR 2590.715-2713(a)(1)(ii). Available at: https://www.govinfo.gov/content/pkg/CFR-2020-title29-vol9/pdf/CFR-2020-title29-vol9-sec2590-715-2713.pdf. Accessed on December 18, 2025.
    • 45 CFR 147.130(a)(1)(ii). Available at: https://www.govinfo.gov/content/pkg/CFR-2019-title45-vol2/pdf/CFR-2019-title45-vol2-sec147-130.pdf. Accessed on December 18, 2025.
14. Infectious Diseases Society of America. Comments for Centers For Disease Control And Prevention: meeting of the advisory committee on immunization practices. September 18-19, 2025. https://www.idsociety.org/globalassets/acip-sept-2025.pdf Accessed December 18, 2025.
15. Infectious Diseases Society of America. Provider letter: MMR travel and outbreak recommendations. April 8, 2025. Available at: https://www.idsociety.org/globalassets/idsa/public-health/measles/2025-provider-letter---mmr-travel-and-outbreak-recommendations.pdf. Accessed on December 18, 2025.
16. United States Food & Drug Administration (FDA). Vaccines Licensed for Use in the United States. Current as of December 16, 2025. Available at: https://www.fda.gov/vaccines-blood-biologics/vaccines/vaccines-licensed-use-united-states. Accessed on December 18, 2025.

1. American Academy of Pediatrics (AAP). Healthy Children. Immunization. Available at: https://www.healthychildren.org/english/safety-prevention/immunizations/Pages/default.aspx. Accessed on December 18, 2025.
2. Centers for Disease Control and Prevention. Vaccine Glossary. Available at: https://www.cdc.gov/vaccines/glossary/. Accessed on December 18, 2025.
3. Centers for Disease Control and Prevention. ACIP Vaccine Recommendations and Guidelines. January 7, 2025. Available at: https://www.cdc.gov/acip-recs/hcp/vaccine-specific/index.html. Accessed on December 18, 2025.

Abrysvo
Arexvy
aIIV3
Bexsero®
Beyfortus
Capvaxive
Enflonsia
FluMist® Trivalent.
FluMist^® Quadrivalent
Gardasil 9^®
HD-IIV3
Hepatitis
Heplisav-B^®
Herpes Zoster
Human Papillomavirus (HPV)
Immunizations
Influenza
Inoculations
Johnson & Johnson’s Janssen
Live attenuated influenza vaccine
Meningococcal
Measles, Mumps, Rubella (MMR)
Moderna
Mpox
mResvia®
Novavax
PCV15
PCV20
PCV21
Penbraya
Penmenvy
Pfizer-BioNTech
Pneumococcal
Poliovirus
Rotarix^®
RotaTeq^®
Rotavirus
RSV
Shingrix^®
Tetanus, Diphtheria (Td)
Tetanus, Diphtheria, Pertussis (Tdap/DTaP)
Vaccines
Varicella
VIMKUNYA

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services are rendered must be used. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically.

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