Coverage of Vaccines Medicaid and Child Health Plus Members

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1 Coverage of Vaccines Medicaid and Child Health Plus Members For children between the ages 0-18, routine recommended vaccinations are covered through Vaccines for Children program [VFC]. Fidelis Care will cover only the administration fee for the vaccines reimbursed under VFC program. Covered without restrictions (Rabies vaccine) Covered for all age groups without restrictions (Rabies vaccine) Covered for all age groups without restrictions Covered with prior authorization (Typhoid vaccine) Covered with prior authorization for all ages (Typhoid vaccine) Covered with prior authorization for all ages (Cholera vaccine) Covered with prior authorization for all ages (Japanese encephalitis virus vaccine) Covered with prior authorization for all ages (Yellow fever vaccine) Covered with prior authorization for all ages (Dtap-IPV) Covered with prior authorization for adults 19 years of age (Dtap-IPV and Haemophilus influenza type b) Covered with prior authorization for adults 19 years of age Covered with age restrictions (Human Papillomavirus vaccine) Covered only for ages 19 years of age through 26 years of age (Human Papillomavirus vaccine) - Covered only for females > 19 years of age through < 25 years of age (Human Papillomavirus vaccine) Covered only for ages 19 years of age through 26 years of age (DTP) Covered for adults 19 years of age (Hepatitis B vaccine) Covered for adults 19 years of age (Tetanus and diphtheria toxoids) Covered for adults 19 years of age (Hepatitis B vaccine) Covered for adults > 19 years of age (Influenza virus vaccine) Covered for adults > 19 years of age (Hepatitis A and Hepatitis B combo vaccine) Covered for adults 19 years of age (Hepatitis A vaccine) Covered for adults 19 years of age (Injectable influenza vaccine) Covered for adults 19 years of age (Nasal influenza vaccine) Covered for adults 19 years of age through (Meningococcal Conjugate vaccine) Covered for adults 19 years of age (Measles, Mumps, and Rubella vaccine) Covered for adults 19 years of age (Tetanus Toxoid and Diphtheria vaccine) Covered for adults 19 years of age (Varicella virus vaccine) Covered for adults 19 years of age (Pneumococcal polysaccharide vaccine) Covered for adults 19 years of age (Zoster (shingles) vaccine) Covered for adults > 50 years of age (Zoster (shingles) vaccine) Covered for adults > 50 years of age 1

2 Not covered (Adenovirus vaccine, type 4) - Not covered (Adenovirus vaccine, type 7) - Not covered (Anthrax vaccine) - Not covered (Bacillus Calmmette-Guerin vaccine for TB live) - Not covered (Bacillus Calmmette-Guerin vaccine for bladder cancer, live) - Not covered (Unlisted vaccine) Not covered, as not specific to a particular vaccine; all recommended vaccines have unique CPT codes 2

3 Fidelis Care New York Coverage of Immunizations for Children (0 to <19 yo) and Adults ( >19 yo) for Child Health Plus [CHP] and Medicaid Managed Care [NYM] CHP and NYM (0 to <19 yo) The Administration fee ONLY will be covered for vaccine CPT codes in the attached Appendix A (reimbursement for the cost of the vaccines themselves should be obtained via Vaccines for Children [VFC] program) *,** The Administration fee and Cost will be reimbursed to MDs for vaccine CPT codes listed below (utilization management controls may apply as noted below). These vaccines are NOT covered via VFC: (Rabies vaccine) covered without restrictions (Rabies vaccine) covered without restrictions (Typhoid vaccine) covered with prior authorization (Typhoid vaccine) covered with prior authorization (Cholera vaccine) covered with prior authorization (Japanese encephalitis virus vaccine) covered with prior authorization (Yellow fever vaccine) covered with prior authorization (Tetanus Toxoid) Covered for ages 7 yo to 18 yo NYM ( > 19 yo) The Administration fee and Cost will be reimbursed to MDs for vaccine CPT codes in the attached Appendix B; utilization management controls may apply (as listed) *** *To become a registered provider with VFC, please go to this website: 3

4 Appendix A COVERED VACCINE CPT CODES FOR CHILDREN UNDER CHP AND NYM (0 to <19 YO) THROUGH VACCINES FOR CHILDREN PROGRAM VACCINE FULL NAME OF VACCINE CPT CODE DTAP (Daptacel, Infanrix) Diphtheria, Tetanus Toxoid, Acellular Pertussis vaccine DtaP-Hep B-IPV (Pediarix) Diphtheria, Tetanus Toxoid, Acellular Pertussis, Hepatitis B e-ipv (Ipol) Inactivated poliovirus vaccine HEPATITIS A PED (Vaqta, Havrix) Hepatitis A Pediatric vaccine HEPATITS A-HEPATITIS B (18 year olds) (Twinrix) Hepatitis A and Hepatitis B combo vaccine HIB (Pedvax) Haemophilus B conjugate vaccine HIB (Acthib, Hiberix) Haemophilus B conjugate vaccine HPV (Gardasil 9) Human Papillomavirus 9 Valent MENB (Bexsero) Meningococcal recombinant protein vaccine MENB (Trumenba) Meningococcal recombinant lipoprotein vaccine MENINGOCOCCAL CONJUGATE (Menactra, Menveo) Meningococcal Conjugate vaccine MMR (MMR II) Measles, Mumps and Rubella vaccine MMR-V (Proquad) Measles, Mumps and Rubella and Varicella Vaccine ROTAVIRUS (RotaTeq) Rotavirus vaccine, live, oral, Pentavalent ROTAVIRUS (Rotarix) Rotavirus vaccine, live, oral VARICELLA (Varivax) Varicella virus vaccine PNEUMOCOCCAL (Prevnar 13) Pneumococcal conjugate vaccine (13 valent) PNEUMOCOCCAL (2 yr and up) (Pneumovax 23) Pneumococcal polysaccharide vaccine (23 valent) TDAP (Boostrix, Adacel) Tetanus Toxoid and Diphtheria and acellular pertussis vaccine DTAP-IPV (Kinrix, Quadracel) Diphtheria, Tetanus Toxoid, Acellular Pertussis vaccine and Inactivated poliovirus vaccine DTAP-IPV-HIB (Pentacel) Diphtheria, Tetanus Toxoid, Acellular Pertussis vaccine and Inactivated poliovirus vaccine and Haemophilus Influenza B vaccine TD (Tenivac, Td vaccine)* Tetanus & Diphtheria Toxoids HEPATITIS B (PED/ADOL) (Engerix B, Recombivax HB) Hepatitis B pediatric/adolescent vaccine INFLUENZA (48 months and up) Influenza virus vaccine, quadrivalent (cciiv4) (Flucelvax Quadrivalent) INFLUENZA (6-35 Months of age) Influenza virus vaccine, quadrivalent (IIV4) (Flulaval Quadrivalent, Fluzone Quadrivalent) INFLUENZA (6-35 Months of age) Influenza vaccine Quadrivalent (Fluzone Quadrivalent) INFLUENZA (36 months of age and up) Influenza vaccine Quadrivalent (Fluzone Quadrivalent, Fluarix Quadrivalent, FluLaval Quadrivalent) INFLUENZA (36 months of age and up) Influenza virus vaccine, quadrivalent (IIV4) (Flulaval Quadrivalent)

5 Appendix B COVERED VACCINE CPT CODES FOR ADULTS UNDER NYM > 19 YO VACCINE FULL NAME OF VACCINE CPT CODE Comments/UM controls Diphtheria Antitoxin Diphtheria Antitoxin Covered, no age restrictions TIG (Baytet) Tetanus immune globulin Covered, no age restrictions HBIG (BayHepB, Nabi-HB) Hepatitis B immune globulin Covered, no age restrictions HEPATITIS A Adult (Havrix) Hepatitis A Adult vaccine Covered for adults > 19 yo HEPATITIS B (Engerix-B, Recombivax-HB) Hepatitis B adult vaccine (40mcg dose) Covered for adults > 19 yo HEPATITIS B (Engerix-B, Recombivax-HB) Hepatitis B adult vaccine Covered for adults >20 yo HEPATITIS B (Engerix-B, Recombivax-HB) Hepatitis B adult dialysis (40mcg dose) Covered for adults > 19 yo HEPATITS A-HEPATITIS B (Twinrix) Hepatitis A and Hepatitis B combo vaccine Covered for adults > 19 yo INFLUENZA (Fluvirin, FluLaval Trivalent, Afluria) Influenza vaccine Covered for adults > 19 yo INFLUENZA (Flumist) Nasal influenza vaccine Covered for adults > 19 yo through <49 INFLUENZA (Fluzone PF, Fluvirin PF, Afluria PF) Influenza vaccine - preservative free Covered for adults > 19 yo MENINGOCOCCAL CONJUGATE (Menactra, Menveo) Meningococcal Conjugate vaccine Covered for adults > 19 yo MMR (M-M-R II) Measles, Mumps and Rubella vaccine Covered for adults > 19 yo VARICELLA (Varivax) Varicella virus vaccine Covered for adults > 19 yo VZIG Varicella zoster immune globulin Covered, no age restrictions PNEUMOCOCCAL (Pneumovax 23) Pneumococcal polysaccharide vaccine 23-valent Covered for adults > 19 yo PNEUMOCOCCAL (Prevnar 13) Pneumococcal conjugate vaccine 13-valent Covered for adults > 19 yo TDAP (Adacel, Boostrix) Tetanus Toxoid, Diphtheria and acellular pertussis vaccine Covered for adults > 19 yo HPV (Gardasil) Human Papillomavirus Quadrivalent (Types 6, 11, 16, 18) Covered only for ages > 19 yo through < 26 HPV (Cervarix) Human Papillomavirus Bivalent (Types 16 & 18) Covered only for females > 19 yo through < 25 HPV (Gardasil 9) Human Papillomavirus 9 Valent Covered only for ages > 19 yo through < 26 INFLUENZA Influenza virus vaccine, quadrivalent (cciiv4) ((Flucelvax Quadrivalent) Covered for adults > 19 yo Rabies vaccine (RabAvert) Rabies vaccine (intramuscular injection) Covered, no age restrictions Rabies vaccine (Immovax Rabies I.D.) Rabies vaccine (intradermal injection) Covered, no age restrictions RIG Rabies immune globulin Covered, no age restrictions Typhoid vaccine, live oral Ty21 (Vivotif Berna) Typhoid vaccine, live, oral Covered, no age restrictions Typhoid (Typhim Vi) Typhoid vaccine, for subcutaneous use Covered, no age restrictions Japanese encephalitis virus vaccine Japanese encephalitis virus vaccine for IM use Covered, no age restrictions Cholera vaccine Cholera vaccine, oral Covered, no age restrictions Yellow fever vaccine Yellow fever vaccine, live, for subcutaneous use Covered, no age restrictions DTAP-IPV (Kinrix) Diphtheria, Tetanus Toxoid, Acellular Pertussis vaccine and Inactivated poliovirus vaccine Covered for adults > 19 yo DTAP-IPV-HIB (Pentacel) Diphtheria, Tetanus Toxoid, Acellular Pertussis vaccine and Covered for adults > 19 yo 5

6 Zoster Vaccine (Zostavax, Shingrix) Inactivated poliovirus vaccine and Haemophilus Influenza B vaccine Zoster (shingles) vaccine, live, subcutaneous injection HEPATITIS A ADULT (Vaqta, Havrix) Hepatitis A Adult vaccine INFLUENZA (Flucelvax PF) Influenza vaccine preservative free INFLUENZA (Fluzone Quadrivalent) Influenza vaccine, Quadrivalent INFLUENZA (Fluzone Quadrivalent, Fluarix Quadrivalent, FluLaval Quadrivalent) Influenza vaccine, Quadrivalent TD (Tenivac) Tetanus & Diphtheria Toxoids HEPATITIS B (Recombivax HB) Hepatitis B adult vaccine HEPATITIS B (Engerix-B) Hepatitis B adult vaccine Covered for adults > 50 yo 6

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