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 90675 (Rabies vaccine) Covered for all age groups without restrictions 90676 (Rabies vaccine) Covered for all age groups without restrictions Covered with prior authorization 90690 (Typhoid vaccine) Covered with prior authorization for all ages 90691 (Typhoid vaccine) Covered with prior authorization for all ages 90625 (Cholera vaccine) Covered with prior authorization for all ages 90738 (Japanese encephalitis virus vaccine) Covered with prior authorization for all ages 90717 (Yellow fever vaccine) Covered with prior authorization for all ages 90696 (Dtap-IPV) Covered with prior authorization for adults 19 years of age 90698 (Dtap-IPV and Haemophilus influenza type b) Covered with prior authorization for adults 19 years of age Covered with age restrictions 90649 (Human Papillomavirus vaccine) Covered only for ages 19 years of age through 26 years of age 90650 (Human Papillomavirus vaccine) - Covered only for females > 19 years of age through < 25 years of age 90651 (Human Papillomavirus vaccine) Covered only for ages 19 years of age through 26 years of age 90701 (DTP) Covered for adults 19 years of age 90747 (Hepatitis B vaccine) Covered for adults 19 years of age 90715 (Tetanus and diphtheria toxoids) Covered for adults 19 years of age 90746 (Hepatitis B vaccine) Covered for adults > 19 years of age 90656 (Influenza virus vaccine) Covered for adults > 19 years of age 90636 (Hepatitis A and Hepatitis B combo vaccine) Covered for adults 19 years of age 90632 (Hepatitis A vaccine) Covered for adults 19 years of age 90658 (Injectable influenza vaccine) Covered for adults 19 years of age 90660 (Nasal influenza vaccine) Covered for adults 19 years of age through 49 90734 (Meningococcal Conjugate vaccine) Covered for adults 19 years of age 90707 (Measles, Mumps, and Rubella vaccine) Covered for adults 19 years of age 90718 (Tetanus Toxoid and Diphtheria vaccine) Covered for adults 19 years of age 90716 (Varicella virus vaccine) Covered for adults 19 years of age 90732 (Pneumococcal polysaccharide vaccine) Covered for adults 19 years of age 90736 (Zoster (shingles) vaccine) Covered for adults > 50 years of age 90750 (Zoster (shingles) vaccine) Covered for adults > 50 years of age 1
Not covered 90476 (Adenovirus vaccine, type 4) - Not covered 90477 (Adenovirus vaccine, type 7) - Not covered 90581 (Anthrax vaccine) - Not covered 90585 (Bacillus Calmmette-Guerin vaccine for TB live) - Not covered 90586 (Bacillus Calmmette-Guerin vaccine for bladder cancer, live) - Not covered 90749 (Unlisted vaccine) Not covered, as not specific to a particular vaccine; all recommended vaccines have unique CPT codes 2
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: 90675 (Rabies vaccine) covered without restrictions 90676 (Rabies vaccine) covered without restrictions 90690 (Typhoid vaccine) covered with prior authorization 90691 (Typhoid vaccine) covered with prior authorization 90625 (Cholera vaccine) covered with prior authorization 90738 (Japanese encephalitis virus vaccine) covered with prior authorization 90717 (Yellow fever vaccine) covered with prior authorization 90703 (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: http://www.cdc.gov/vaccines/programs/vfc/providers/questions/qa-join.html 3
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 90700 DtaP-Hep B-IPV (Pediarix) Diphtheria, Tetanus Toxoid, Acellular Pertussis, Hepatitis B 90723 e-ipv (Ipol) Inactivated poliovirus vaccine 90713 HEPATITIS A PED (Vaqta, Havrix) Hepatitis A Pediatric vaccine 90633 HEPATITS A-HEPATITIS B (18 year olds) (Twinrix) Hepatitis A and Hepatitis B combo vaccine 90636 HIB (Pedvax) Haemophilus B conjugate vaccine 90647 HIB (Acthib, Hiberix) Haemophilus B conjugate vaccine 90648 HPV (Gardasil 9) Human Papillomavirus 9 Valent 90651 MENB (Bexsero) Meningococcal recombinant protein vaccine 90620 MENB (Trumenba) Meningococcal recombinant lipoprotein vaccine 90621 MENINGOCOCCAL CONJUGATE (Menactra, Menveo) Meningococcal Conjugate vaccine 90734 MMR (MMR II) Measles, Mumps and Rubella vaccine 90707 MMR-V (Proquad) Measles, Mumps and Rubella and Varicella Vaccine 90710 ROTAVIRUS (RotaTeq) Rotavirus vaccine, live, oral, Pentavalent 90680 ROTAVIRUS (Rotarix) Rotavirus vaccine, live, oral 90681 VARICELLA (Varivax) Varicella virus vaccine 90716 PNEUMOCOCCAL (Prevnar 13) Pneumococcal conjugate vaccine (13 valent) 90670 PNEUMOCOCCAL (2 yr and up) (Pneumovax 23) Pneumococcal polysaccharide vaccine (23 valent) 90732 TDAP (Boostrix, Adacel) Tetanus Toxoid and Diphtheria and acellular pertussis vaccine 90715 DTAP-IPV (Kinrix, Quadracel) Diphtheria, Tetanus Toxoid, Acellular Pertussis vaccine and Inactivated poliovirus vaccine 90696 DTAP-IPV-HIB (Pentacel) Diphtheria, Tetanus Toxoid, Acellular Pertussis vaccine and Inactivated poliovirus vaccine and Haemophilus Influenza B vaccine 90698 TD (Tenivac, Td vaccine)* Tetanus & Diphtheria Toxoids 90714 HEPATITIS B (PED/ADOL) (Engerix B, Recombivax HB) Hepatitis B pediatric/adolescent vaccine 90744 INFLUENZA (48 months and up) Influenza virus vaccine, quadrivalent (cciiv4) (Flucelvax Quadrivalent) 90674 90756 INFLUENZA (6-35 Months of age) Influenza virus vaccine, quadrivalent (IIV4) (Flulaval Quadrivalent, Fluzone Quadrivalent) 90687 INFLUENZA (6-35 Months of age) Influenza vaccine Quadrivalent (Fluzone Quadrivalent) 90685 INFLUENZA (36 months of age and up) Influenza vaccine Quadrivalent (Fluzone Quadrivalent, Fluarix Quadrivalent, FluLaval Quadrivalent) 90686 INFLUENZA (36 months of age and up) Influenza virus vaccine, quadrivalent (IIV4) (Flulaval Quadrivalent) 90688 4
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 90296 Covered, no age restrictions TIG (Baytet) Tetanus immune globulin 90389 Covered, no age restrictions HBIG (BayHepB, Nabi-HB) Hepatitis B immune globulin 90371 Covered, no age restrictions HEPATITIS A Adult (Havrix) Hepatitis A Adult vaccine 90632 Covered for adults > 19 yo HEPATITIS B (Engerix-B, Recombivax-HB) Hepatitis B adult vaccine (40mcg dose) 90740 Covered for adults > 19 yo HEPATITIS B (Engerix-B, Recombivax-HB) Hepatitis B adult vaccine 90746 Covered for adults >20 yo HEPATITIS B (Engerix-B, Recombivax-HB) Hepatitis B adult dialysis (40mcg dose) 90747 Covered for adults > 19 yo HEPATITS A-HEPATITIS B (Twinrix) Hepatitis A and Hepatitis B combo vaccine 90636 Covered for adults > 19 yo INFLUENZA (Fluvirin, FluLaval Trivalent, Afluria) Influenza vaccine 90658 Covered for adults > 19 yo INFLUENZA (Flumist) Nasal influenza vaccine 90660 Covered for adults > 19 yo through <49 INFLUENZA (Fluzone PF, Fluvirin PF, Afluria PF) Influenza vaccine - preservative free 90656 Covered for adults > 19 yo MENINGOCOCCAL CONJUGATE (Menactra, Menveo) Meningococcal Conjugate vaccine 90734 Covered for adults > 19 yo MMR (M-M-R II) Measles, Mumps and Rubella vaccine 90707 Covered for adults > 19 yo VARICELLA (Varivax) Varicella virus vaccine 90716 Covered for adults > 19 yo VZIG Varicella zoster immune globulin 90396 Covered, no age restrictions PNEUMOCOCCAL (Pneumovax 23) Pneumococcal polysaccharide vaccine 23-valent 90732 Covered for adults > 19 yo PNEUMOCOCCAL (Prevnar 13) Pneumococcal conjugate vaccine 13-valent 90670 Covered for adults > 19 yo TDAP (Adacel, Boostrix) Tetanus Toxoid, Diphtheria and acellular pertussis vaccine 90715 Covered for adults > 19 yo HPV (Gardasil) Human Papillomavirus Quadrivalent (Types 6, 11, 16, 18) 90649 Covered only for ages > 19 yo through < 26 HPV (Cervarix) Human Papillomavirus Bivalent (Types 16 & 18) 90650 Covered only for females > 19 yo through < 25 HPV (Gardasil 9) Human Papillomavirus 9 Valent 90651 Covered only for ages > 19 yo through < 26 INFLUENZA Influenza virus vaccine, quadrivalent (cciiv4) ((Flucelvax Quadrivalent) 90674 Covered for adults > 19 yo Rabies vaccine (RabAvert) Rabies vaccine (intramuscular injection) 90675 Covered, no age restrictions Rabies vaccine (Immovax Rabies I.D.) Rabies vaccine (intradermal injection) 90676 Covered, no age restrictions RIG Rabies immune globulin 90375 Covered, no age restrictions Typhoid vaccine, live oral Ty21 (Vivotif Berna) Typhoid vaccine, live, oral 90690 Covered, no age restrictions Typhoid (Typhim Vi) Typhoid vaccine, for subcutaneous use 90691 Covered, no age restrictions Japanese encephalitis virus vaccine Japanese encephalitis virus vaccine for IM use 90738 Covered, no age restrictions Cholera vaccine Cholera vaccine, oral 90625 Covered, no age restrictions Yellow fever vaccine Yellow fever vaccine, live, for subcutaneous use 90717 Covered, no age restrictions DTAP-IPV (Kinrix) Diphtheria, Tetanus Toxoid, Acellular Pertussis vaccine and Inactivated poliovirus vaccine 90696 Covered for adults > 19 yo DTAP-IPV-HIB (Pentacel) Diphtheria, Tetanus Toxoid, Acellular Pertussis vaccine and 90698 Covered for adults > 19 yo 5
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 90633 INFLUENZA (Flucelvax PF) Influenza vaccine preservative free 90661 INFLUENZA (Fluzone Quadrivalent) Influenza vaccine, Quadrivalent 90685 INFLUENZA (Fluzone Quadrivalent, Fluarix Quadrivalent, FluLaval Quadrivalent) Influenza vaccine, Quadrivalent 90686 TD (Tenivac) Tetanus & Diphtheria Toxoids 90714 HEPATITIS B (Recombivax HB) Hepatitis B adult vaccine 90743 90746 90744 90746 HEPATITIS B (Engerix-B) Hepatitis B adult vaccine 90747 90736 90750 Covered for adults > 50 yo 6