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 obtained from the 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 • 90585 (Bacillus Calmette-Guerin vaccine) – Covered for all age groups without restrictions Covered with age restrictions • 90620 (Meningococcal recombinant vaccine) – Covered for adults ≥ 19 years of age • 90621 (Meningococcal recombinant vaccine) – Covered for adults ≥ 19 years of age • 90625 (Cholera vaccine) – Covered for adults ≥ 18 years of age through ≤ 64 years of age • 90632 (Hepatitis A vaccine) – Covered for adults ≥ 19 years of age • 90636 (Hepatitis A and Hepatitis B combo vaccine) – Covered for adults ≥ 19 years of age • 90648 (Haemophilus Influenzae Type B vaccine) – Covered only for ages ≥ 19 years of age • 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 ≤ 45 years of age • 90653 (Influenza virus vaccine) – Covered for adults ≥ 65 years of age • 90654 (Influenza virus vaccine) – Covered for adults ≥ 19 years of age • 90656 (Influenza virus vaccine) – Covered for adults ≥ 19 years of age • 90657 (Influenza virus 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 • 90662 (Influenza virus vaccine) – Covered for adults ≥ 65 years of age • 90670 (Pneumococcal conjugate vaccine) – Covered for adults ≥ 19 years of age • 90682 (Injectable influenza vaccine) – Covered for adults ≥ 19 years of age • 90690 (Typhoid Vaccine) – Covered for ≥ 6 years of age • 90691 (Typhoid Vaccine) – Covered for ≥ 2 years of age • 90698 (Dtap-IPV and Haemophilus influenza type b) – Covered for adults ≥ 19 years of age • 90707 (Measles, Mumps, and Rubella vaccine) – Covered for adults ≥ 19 years of age • 90715 (Tetanus and diphtheria toxoids) – Covered for adults ≥ 19 years of age • 90716 (Varicella virus vaccine) – Covered for adults ≥ 19 years of age • 90717 (Yellow fever vaccine) – Covered for ≥ 6 months of age • 90732 (Pneumococcal polysaccharide vaccine) – Covered for adults ≥ 19 years of age • 90734 (Meningococcal Conjugate vaccine) – Covered for adults ≥ 19 years of age • 90736 (Zoster (shingles) vaccine) – Covered for adults ≥ 50 years of age Fidelis Care Provider Manual V19.0-1/1/2019 1 • 90738 (Japanese encephalitis virus vaccine) – Covered for ≥ 2 months of age • 90739 (Hepatitis B vaccine) – Covered for adults ≥ 19 years of age • 90740 (Hepatitis B vaccine) – Covered for adults ≥ 19 years of age • 90746 (Hepatitis B vaccine) – Covered for adults ≥ 19 years of age • 90747 (Hepatitis B vaccine) – Covered for adults ≥ 19 years of age • 90750 (Zoster (shingles) vaccine) – Covered for adults ≥ 50 years of age Not covered • 90749 (Unlisted vaccine) – Not covered, as not specific to a particular vaccine; all recommended vaccines have unique CPT codes Fidelis Care Provider Manual V19.0-1/1/2019 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) NYM (≥19 yo) The Administration fee ONLY will be covered for vaccine The Administration CPT codes in the attached Appendix A (reimbursement for the fee and Cost will be cost of the vaccines themselves should be obtained via reimbursed to MDs Vaccines for Children [VFC] program)*,** for vaccine CPT codes in the attached The Administration fee and Cost will be reimbursed to MDs Appendix B; for vaccine CPT codes listed below (utilization management utilization controls may apply as noted below). These vaccines are NOT management covered via VFC: controls may apply (as listed)*** 90675 (Rabies vaccine) – covered without restrictions 90676 (Rabies vaccine) – covered without restrictions 90690 (Typhoid vaccine) – covered for ≥ 6 years of age 90691 (Typhoid vaccine) – covered for ≥ 2 years of age 90625 (Cholera vaccine) – covered for adults ≥ 18 years of age through ≤ 64 years of age 90738 (Japanese encephalitis virus vaccine) – covered for ≥ 2 months of age 90717 (Yellow fever vaccine) – covered for ≥ 6 months of age 90585 (Bacillus Calmette-Guerin vaccine) – covered without restrictions *To become a registered provider with VFC, please go to this website: http://www.cdc.gov/vaccines/programs/vfc/providers/questions/qa-join.html Fidelis Care Provider Manual V19.0-1/1/2019 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 Diphtheria, Tetanus Toxoid, Acellular Pertussis vaccine and Inactivated poliovirus vaccine and DTAP-IPV-HIB (Pentacel) 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 Nasal (2 years and up) Influenza virus vaccine, quadrivalent (FluMist) 90672 90674 INFLUENZA (48 months and up) Influenza virus vaccine, quadrivalent (ccIIV4) (Flucelvax Quadrivalent) 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 Fidelis Care Provider Manual V19.0-1/1/2019 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 CMV-IgIV (Cytogam) Cytomegalovirus immune globulin 90291 Covered, no age restrictions 90384 Covered, females only RhIg IM (HyperRHO,RhoGAM) Rho(D) Immune Globulin intramuscular 90385 RhIgIV (WinRho) Rho(D) Immune Globulin intravenous 90386 Covered, no age restrictions BCG vaccine Bacillus Calmette-Guerin vaccine 90585 Covered, no age restrictions BCG intravesical (Tice BCG) Bacillus Calmmette-Guerin vaccine for bladder cancer, live 90586 Covered, no age restrictions HiB (ActHIB, Hiberix) Haemophilus influenzae B vaccine 90648 Covered for adults ≥ 19 yo HEPATITIS A Adult (Havrix) Hepatitis A Adult vaccine 90632 Covered for adults ≥ 19 yo HEPATITS A-HEPATITIS B (Twinrix) Hepatitis A and Hepatitis B combo vaccine 90636 Covered for adults ≥ 19 yo INFLUENZA (Fluad) Influenza vaccine 90653 Covered for adults ≥ 65 yo INFLUENZA Influenza vaccine (intradermal) 90654 Covered for adults ≥ 19 yo INFLUENZA (Fluzone) Influenza vaccine 90657 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 MENINGOCOCCAL RECOMBINANT, 90620 (Trumenba, Bexsero) Meningococcal recombinant vaccine 90621 Covered for adults ≥ 19 yo MMR (M-M-R II) Measles, Mumps and Rubella vaccine 90707 Covered for adults ≥ 19 yo VARICELLA