90683 CPT® code: payer coverage and prior authorization

Payer policies and prior authorization for 90683

Payer coverage policies that name 90683

90683 appears in 4 coverage policies from Aetna, Blue Cross & Blue Shield of Rhode Island, BlueCross BlueShield of South Carolina.

PayerPolicyRole in policyReviewedDocument
AetnaPalivizumab (Synagis) (0318)listed, no stanceAug 21, 2026payer document
AetnaRespiratory Syncytial Virus (RSV) Vaccines for Adult and Maternal Use (1027)covered if criteria are metOct 9, 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)
90677 (effective 12/15/2021) | Pneumococcal conjugate vaccine, 20 valent (PCV20), for intramuscular use | Both		listed, no stanceApr 1, 2026payer document

Medicaid fee-for-service

Prior authorization required or conditional in IN.

  • AZ: $319.00 (outpatient_hospital), effective Jul 1, 2026
  • FL: $290.00 (immunization), effective Jul 1, 2026
  • IL: $304.96 (practitioner), effective Apr 1, 2026
  • KS: $290.00 (default), effective Jun 26, 2024
  • KY: $274.40 (physician, non-facility), effective Jan 1, 2026
  • ND: $290.00 (physician), effective Aug 1, 2026
  • OK: $271.53 (physician, non-facility), effective Jul 1, 2026
  • TX: $311.46 (certified_nurse_midwife_cnm, Certified Nurse Midwife (Cnm), non-facility), effective Oct 1, 2024
  • VA: $290.00 (medical), effective May 31, 2024
  • VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
  • WA: $319.00 (professional_administered_drugs), 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.