Reimbursement information
| Commercial insurance |
CAPVAXIVE is covered for ~99% of commercial medical lives, as of June 20251
CAPVAXIVE is covered by a network of national plans, including United Healthcare, CVS Aetna, and CIGNA.1
Commercial insurance may provide coverage for employed adult patients aged 19 to 64 years.
Consult private insurer or public program for reimbursement details.
| Medicare and Medicaid |
Pneumococcal vaccines covered under Part B are available to Medicare beneficiaries at $0 out of pocket2
CAPVAXIVE is covered by both Medicaid and Medicare as both follow ACIP recommendations for pneumococcal vaccination coverage to ensure that eligible beneficiaries receive appropriate vaccinations.2,3
State Medicaid agencies may be required to cover approved adult ACIP-recommended vaccinations for most beneficiaries.3
Medicare began covering CAPVAXIVE effective June 27, 2024.2
Consult private insurer or public program for reimbursement details.
| CAPVAXIVE CPT code4: 90684 |
The information provided here is compiled from sources believed to be accurate, but Merck makes no representation that it is accurate. Consult the relevant manual and/or other guidelines for a description of each code to determine the appropriateness of a particular code and for information on additional codes. This information is subject to change. Merck cautions that payer coding requirements vary and can frequently change, so it’s important to regularly check with each payer as to payer-specific requirements.
You are solely responsible for determining the appropriate codes and for any action you take in billing. The information provided here is not intended to be definitive or exhaustive, and is not intended to replace the guidance of a qualified professional advisor. Merck makes no warranties or guarantees, expressed or implied, concerning the accuracy or appropriateness of this information for your particular use given the frequent changes in public and private payer billing. The use of this information does not guarantee payment or that any payment received will cover your costs. Diagnosis codes should be selected only by a health care professional.
Remember: The reimbursement-related information in this resource is general in nature. This information is subject to change. It is not intended to be exhaustive, nor to replace the guidance of a qualified reimbursement advisor, and does not constitute legal or reimbursement advice. The use of the information presented here is not a guarantee of coverage or payment. As a provider, you are solely responsible for billing payers correctly and for determining whether any payer-specific guidelines apply. Merck does not guarantee or ensure the timeliness or appropriateness of this information for your particular use given the frequent changes in public and private payer billing.
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CPT, Current Procedural Terminology. CPT is a registered trademark of the American Medical Association.
NDC, National Drug Code.
References:
- Data available on request from Merck National Service Center via email at daprequests@merck.com. Please specify information package US-PVV-01008.
- Revisions to Medicare Part B coverage of pneumococcal vaccinations policy. MLN Matters Number: MM13750. Medicare Learning Network. Centers for Medicare & Medicaid Services. Implementation date November 25, 2024. Accessed March 20, 2025. https://www.cms.gov/files/document/mm13750-revisions-medicare-part-b-coverage-pneumococcal-vaccinations-policy.pdf
- Quality of care vaccines. Medicaid.gov. Accessed March 6, 2025. https://www.medicaid.gov/medicaid/quality-of-care/quality-improvement-initiatives/quality-of-care-vaccines/index.html
- Immunization information systems (IIS). CPT codes mapped to CVX codes. Centers for Disease Control and Prevention. Last reviewed November 26, 2025. Accessed January 8, 2026. https://www2a.cdc.gov/vaccines/iis/iisstandards/vaccines.asp?rpt=cpt