Annual Vaccine Coverage Update

The changes in this update apply to all groups that use OptumRx

Vaccine & Immunization Coverage

This bulletin reflects vaccine coverage based on current FDA approvals and CDC/ACIP recommendations as of October 2025. Members are encouraged to consult with their healthcare providers for personalized vaccination decisions.

Covered vaccines and immunizations align with those listed on the ACA HCR preventive medication list. Please note, coverage may change in response to future guideline updates.

Seasonal Vaccine Coverage

Flu Vaccine Coverage

Flu vaccines are covered under the member’s pharmacy benefit when administered at any in-network pharmacy. An administration fee may apply, which is the responsibility of the employer group. Members who receive flu vaccines at out-of-network pharmacies are responsible for the full cost. For information on flu vaccine coverage available through the medical benefit, members should refer to their plan materials.

Please note Planned Administrators, Inc. does not host flu vaccine clinics for employer groups.

Who Is Covered for Seasonal Flu Vaccines?

Flu vaccine coverage automatically applies to all applicable non-grandfathered Fully Insured, ASO, and Exchange membership. These members receive flu vaccines at a $0 copay. Grandfathered groups may elect seasonal flu vaccine coverage at either a $0 or associated plan copay.

Covered Flu Vaccines 

The following flu vaccines are covered under the program this year for both commercial and ACA members:

• Afluria
• Fluad (≥65 yrs)
• Fluarix
• Flublok (≥9 yrs)
• Flucelvax
• FluLaval
• FluMist Intranasal* (ages 2-49 yrs)
• Fluzone
• Fluzone High-Dose PF (≥65 yrs)

*Recently approved for self- or caregiver administration

Flu Treatment Coverage

For members diagnosed by a medical professional with acute uncomplicated influenza (A or B) the following treatments are covered under the pharmacy benefit:

• Oseltamivir (Tamiflu)
• Xofluza – Approved for treatment in patients 5 years of age or older

Covered Covid-19 Vaccines 

FDA-approved COVID-19 vaccines are covered at no cost to the member under the ACA HCR $0 covered drug program.

• Comirnaty
• mNEXSPIKE
• Nuvaxovid
• Spikevax

Non-seasonal Vaccine Coverage

All members whose groups must adhere to ACA regulations (non-grandfathered groups), commercial members with this benefit election, and all ACA members have coverage for the following vaccines. Similar to seasonal flu vaccines, grandfathered groups can choose non-seasonal vaccine coverage with either a $0 copay or associated plan copay. 

^ Approved Feb. 2025; first pentavalent MenABCWY vaccine for ages 10–25.
*Only RSV vaccine approved for use during pregnancy (32-36 weeks gestation). 

Important Updates

FDA Updates

FDA requires a Guillain-Barré syndrome (GBS) warning for Arexvy and Abrysvo, noting increased risk within 42 days of administration.

ACA Coverage Updates

Expanded coverage includes:

• mNEXSPIKE and Nuvaxovid COVID-19 vaccines
• Penmenvy meningococcal B vaccine
• Shingrix for immunocompromised adults (18+)
• Polio vaccination for unvaccinated/incompletely vaccinated adults
• Mpox vaccination for high-risk adults