90657 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 90657

Payer coverage policies that name 90657

90657 appears in 4 coverage policies from Aetna, Blue Cross & Blue Shield of Rhode Island, BlueCross BlueShield of South Carolina.

PayerPolicyRole in policyReviewedDocument
AetnaInfluenza Vaccines (0035)covered if criteria are metOct 8, 2026payer document
AetnaInjectable Medications (0020)listed, no stance (range 90581-90658)Mar 5, 2026payer document
Blue Cross & Blue Shield of Rhode IslandImmunizations Adult and Pediatriccovered if criteria are metJun 9, 2026payer document
BlueCross BlueShield of South CarolinaPreventive Services for Non-Grandfathered (PPACA) Plans: Immunizations (CAM 109)listed, no stanceApr 1, 2026payer document

Medicaid fee-for-service

  • AZ: $11.03 (outpatient_hospital), effective Oct 1, 2025
  • CO: $11.03 (chp_plus_immunizations), effective Jul 1, 2026
  • IL: $16.26 (practitioner), effective Apr 1, 2025
  • IN: $8.36 (professional, Advanced Practice Nurse (85%), non-facility), effective Oct 1, 2025
  • KS: $11.14 (default), effective Oct 1, 2026
  • KY: $0.00 (asc), effective Jan 1, 2026
  • LA: $11.03 (immunization_19_20), effective Jul 1, 2026
  • MS: $6.02 (comprehensive), effective Jul 1, 2014
  • ND: $11.03 (physician), effective Aug 1, 2026
  • OH: $10.93 (provider_administered_drugs), effective Oct 1, 2025
  • OK: $10.33 (physician, non-facility), effective Jul 1, 2026
  • VA: $11.14 (medical), effective Aug 1, 2026
  • VT: $10.48 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $11.03 (professional_administered_drugs), effective Jul 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.