90381 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 90381

Payer coverage policies that name 90381

90381 appears in 7 coverage policies from Aetna, Blue Cross & Blue Shield of Rhode Island, Capital Blue Cross, Centene.

PayerPolicyRole in policyReviewedDocument
AetnaClesrovimab-cfor (Enflonsia) (1088)listed, no stanceOct 9, 2026payer document
AetnaInjectable Medications (0020)listed, no stance (range 90281-90399)Mar 5, 2026payer document
AetnaNirsevimab-alip (Beyfortus) (1038)covered if criteria are metOct 9, 2026payer document
AetnaPalivizumab (Synagis) (0318)listed, no stanceAug 21, 2026payer document
Blue Cross & Blue Shield of Rhode IslandImmunizations Adult and Pediatric
MEDICAL COVERAGE POLICY | 4		covered if criteria are metJun 9, 2026payer document
Capital Blue CrossExperimental and Investigational Procedures (MP 4.002)
Procedure codes: Vaccines		listed, no stanceSep 1, 2026payer document
CenteneNirsevimab-alip (Beyfortus) (CP.PHAR.614)covered if criteria are metAug 1, 2026payer document

Medicaid fee-for-service

  • AZ: $595.06 (outpatient_hospital), effective Jan 1, 2026
  • CO: $596.06 (chp_plus_immunizations), effective Jul 1, 2026
  • FL: $0.00 (immunization), effective Jul 1, 2026
  • IL: $16.26 (practitioner), effective Oct 1, 2024
  • IN: $0.00 (professional, Advanced Practice Nurse (85%), non-facility), effective Jul 17, 2023
  • KS: $0.00 (default), effective Oct 1, 2023
  • KY: $485.10 (physician, non-facility), effective Jan 1, 2026
  • LA: $0.00 (immunization_0_18), effective Aug 3, 2023
  • ND: $0.00 (physician), effective Aug 1, 2026
  • NE: $10.92 (injectables), effective Jul 1, 2026
  • OK: $463.47 (physician, non-facility), effective Jul 1, 2026
  • VA: $519.75 (medical), effective Apr 1, 2024
  • VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $2.67 (enhanced_pediatric, facility), effective Jul 1, 2026
  • WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.