Payer policies › CPT 9075090750 CPT® code: payer coverage and prior authorizationPayer policies and prior authorization for 90750 Payer coverage policies that name 90750 90750 appears in 2 coverage policies from Aetna, Blue Cross & Blue Shield of Rhode Island.
Payer Policy Role in policy Reviewed Document Aetna Varicella and Herpes Zoster Vaccines (0115) covered if criteria are met Mar 19, 2026 payer document Blue Cross & Blue Shield of Rhode Island Immunizations Adult and PediatricMEDICAL COVERAGE POLICY | 5 covered if criteria are met Jun 9, 2026 payer document
Medicaid fee-for-service AZ: $234.69 (outpatient_hospital), effective Jul 1, 2026 CO: $215.51 (chp_plus_immunizations), effective Jul 1, 2026 FL: $215.51 (immunization), effective Jul 1, 2026 IL: $206.03 (practitioner), effective Apr 1, 2025 IN: $192.35 (professional, Advanced Practice Nurse (85%), non-facility), effective Apr 1, 2026 KS: $215.51 (default), effective Apr 1, 2026 KY: $280.00 (physician, non-facility), effective Jan 1, 2026 LA: $215.51 (immunization_21_plus), effective Jan 1, 2025 MS: $151.41 (comprehensive), effective Jul 1, 2020 ND: $234.69 (physician), effective Aug 1, 2026 OH: $149.80 (provider_administered_drugs), effective Apr 1, 2026 OK: $219.74 (physician, non-facility), effective Jul 1, 2026 TX: $231.46 (certified_nurse_midwife_cnm, Certified Nurse Midwife (Cnm), non-facility), effective Sep 1, 2025 VA: $171.57 (medical), effective Jul 1, 2022 VT: $155.48 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $234.69 (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.