Coverage Policies

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Current policies effective through April 30, 2024.

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Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.


Effective Date: 01/01/2002 Title: Hepatitis A Vaccine
Revision Date: 09/01/2018 Document: BI120:00
CPT Code(s): 90632-9634, 90636
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Hepatitis A vaccine is recommended for routine immunization of all infants and small children. QualChoice covers this vaccine under the preventive benefit without preauthorization for all infants and children under the age of 18.

a)  Infants and small children are the most likely to get hepatitis A.

b)  Infants and small children are rarely ill from hepatitis A, but they do spread it to older people in their surroundings.

2)    Hepatitis A vaccine is not recommended for immunization of adults without risk factors (unless there is a documented community outbreak) and is therefore covered for adults (age 18 and older) with increased risk under the medical benefit without preauthorization.

3)    Hepatitis A vaccine may be recommended based on certain occupations or for travel to countries where Hepatitis A is prevalent, however, QualChoice plans do not provide coverage for these uses.

Medical Statement

1)    QualChoice covers (under the preventive benefit) routine vaccination in either the 2-dose or 3-dose schedule of infants and children under 18 years of age. Physicians are encouraged to vaccinate children at 12 to 23 months of age, since it is of maximum public health benefit when infants are immunized.

2)    Hepatitis A vaccine is considered medically necessary (under the medical benefit) for adults (ages 18 and older) only in the following scenarios:

a)    Men who have sex with men

b)    Persons with chronic liver disease. including hepatitis C

c)    HIV Infection

d)    Close personal contact with international adoptee

e)    Injection or noninjection drug use

f)     Persons experiencing homelessness

g)    Pregnancy

h)    If member requests the Hepatitis A vaccine due to high risk

Codes Used In This BI:


Hepatitis A vaccine, adult dosage, for IM use


Hepatitis A vaccine, pediatric/adoles dosage – 2 dose sched, for IM use


Hepatitis A vaccine, pediatric/adoles dosage – 3 dose sched, for IM use


Hepatitis A & Hepatitis B vaccine (HepA-HepB), adult dosage, for IM use


Hepatitis A vaccine is excluded from coverage for the following categories:

    1. Travelers to areas where hepatitis A is endemic
    2. Military personnel
    3. Individuals with occupational risk of exposure, such as child-care and institutional workers, as well as primate-animal handlers
    4. Laboratory workers who handle live hepatitis A virus.


Studies in Israel and other places indicate that immunization of infants for hepatitis A is effective in reducing the rate at which adults acquire the disease. Hepatitis A is spread by fecal-oral transmission, a common mode of transmission to and among infants, and from infants to adults. Infants serve as an asymptomatic reservoir of hepatitis A virus to infect hepatitis A-naïve adults. Immunizing infants is advocated in areas of low endemnicity now, not because of the protective effect it has on the children, but because of the benefit such immunization provides to adults in the same community.


1.    Hepatitis A in Hispanic Children Who Live Along the United States–Mexico Border: The Role of International Travel and Food-Borne Exposures; Pediatrics at:

2.    Prevention of hepatitis A infections: guidelines for use of hepatitis A vaccine and immune globulin. American Academy of Pediatrics Committee on Infectious Diseases; Pediatrics at:

3.    Prevention of hepatitis A through active or passive immunization.  Recommendations of the Advisory Committee on Immunization Practices (ACIP) 2006.  Accessed 1 July 2014 at:

4. Accessed September 5, 2023.


1)    Effective 01/01/2019: Remove PA requirements for vaccine. Will be covered as routine preventive benefit for ages <18 years old and under the medical benefit as medically necessary under certain scenarios for ages >18 years or older.

2)    Effective 09/01/2021: Added verbiage to remove restrictions on testing.

3)    Effective 09/01/2023: Updated risk factors.

Application to Products

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD,  EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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