`90650` CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 90650

Payer coverage policies that name 90650

90650 appears in 4 coverage policies from Aetna, Blue Cross & Blue Shield of Rhode Island, BlueCross BlueShield of South Carolina.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Human Papillomavirus (HPV) Vaccine (0726)	not covered	Nov 25, 2025	payer document
Aetna	Injectable Medications (0020)	listed, no stance (range 90581-90658)	Mar 5, 2026	payer document
Blue Cross & Blue Shield of Rhode Island	Immunizations Adult and Pediatric MEDICAL COVERAGE POLICY \| 7	covered if criteria are met	Jun 9, 2026	payer document
BlueCross BlueShield of South Carolina	Human Papillomavirus (HPV) Vaccines (CAM 026)	listed, no stance	May 1, 2026	payer document

Medicaid fee-for-service

CO: $180.76 (chp_plus_immunizations), effective Jul 1, 2026
IN: $114.24 (professional, Advanced Practice Nurse (85%), non-facility), effective Oct 1, 2013
KY: $128.75 (physician, non-facility), effective Jan 1, 2026
LA: $131.84 (immunization_19_20), effective Jan 1, 2020
OH: $136.96 (provider_administered_drugs), effective Sep 1, 2013
VA: $253.60 (medical), effective Jul 1, 2022
VT: $0.00 (outpatient_hospital_opps), effective Feb 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.

90650 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 90650

Payer coverage policies that name 90650

Medicaid fee-for-service

`90650` CPT® code: payer coverage and prior authorization