1-888-566-0008, 1-800-900-1451, www.bmchp.org CPT/HCPCS Medication Code Reference List Prior Authorization Code Description Required Immune Globulin (Ig), human, for intramuscular use (Code price is 90281 per 2 mL) Immune Globulin (IgIV), human, for intravenous use (Further 90283 Documentation Requested) Yes Immune Globulin (SCIg), human, for use in subcutaneous infusions, 90284 100 mg, each 90287 Botulinum antitoxin, equine, any route 90288 Botulism immune globulin, human, for intravenous use Cytomegalovirus immune globulin (CMV‐IgIV), human, for 90291 intravenous use 90296 Diphtheria antitoxin, equine, any route Hepatitis B Immune Globulin (HBIg), human, for intramuscular use 90371 (Code Price is per 1 mL) Rabies Immune Globulin (RIg), human, for intramuscular and/or 90375 subcutaneous use Rabies Immune Globulin, heat‐treated (RIg‐HT), human, for 90376 intramuscular and/or subcutaneous use (Code Price is per 150 IU) Respiratory syncytial virus, monoclonal antibody, recombinant, for 90378 intramuscular use, 50 mg, each Rho(D) Immune Globulin (RhIg), human, full dose, for intramuscular 90384 use. Rho(D) Immune Globulin (RhIg), human, mini dose, for 90385 intramuscular use. (Code Price is per 50 mcg) Rho(D) Immune Globulin (RhIgIV), human, for intravenous use (Code 90386 Price is per 1500 IU) This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA. Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 1 of 35 Prior Authorization Code Description Required 90389 Tetanus Immune Globulin (TIg), human, for intramuscular use 90393 Vaccinia immune globulin, human, for intramuscular use Varicella‐zoster Immune Globulin, human, for intramuscular use. 90396 (Code Price is per 125 units) 90476 Adenovirus vaccine, type 4, live, for oral use 90477 Adenovirus vaccine, type 7, live, for oral use 90581 Anthrax vaccine, for subcutaneous use (Code price is per 0.5 mL) Bacillus Calmette‐Guerin vaccine (BCG) for tuberculosis, live, for 90585 percutaneous use (Code Price is per 50 mg) Bacillus Calmette‐Guerin vaccine (BCG) for bladder cancer, live, for 90586 intravesical use. Hepatitis A vaccine, adult dosage, for intramuscular use (Code Price 90632 is per 1 mL) Hepatitis A vaccine, pediatric/adolescent dosage (2‐dose schedule), 90633 for intramuscular use (Code Price is per 0.5 mL) Hepatitis A vaccine, pediatric/adolescent dosage‐3 dose schedule, 90634 for intramuscular use Hepatitis A & Hepatitis B vaccine (HepA‐HepB) adult dosage, for 90636 intramuscular use. (Code Price is per 1 mL) Hemophilus influenza b vaccine (Hib), HbOC conjugate (4‐dose 90645 schedule), for intramuscular use. Hemophilus influenza b vaccine (Hib), PRP‐OMP conjugate (3‐dose 90647 schedule), for intramuscular use. (Code price is per dose = 0.5 mL) Hemophilus influenza b vaccine (Hib), PRP‐T conjugate (4‐dose 90648 schedule), for intramuscular use. (Code price is per 0.5mL dose) Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 90649 (quadrivalent), 3 dose schedule, for intramuscular use Yes for females less than 10 or greater than 26 Human Papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose years old and all 90650 schedule, for intramuscular use males This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA. Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 2 of 35 Prior Authorization Code Description Required Influenza virus vaccine, split virus, preservative free, for children 6‐ 90655 35 months of age, for intramuscular use (Code price is per 0.25 mL) Influenza virus vaccine, split virus, preservative free, for use in individuals 3 years of age and above, for intramuscular use (Code price is per 0.5 mL) (Note: Fluvirin is indicated for use in those 4 90656 years of age and older) Influenza virus vaccine, split virus, for children 6‐35 months of age, 90657 for intramuscular use (Code Price is per 0.25 mL dose) Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use (Code price is per 0.5 mL)(Note: Fluvirin is indicated for use in those 4 years of age and 90658 older) Influenza virus vaccine, live, for intranasal use (Code price is per 0.5 90660 mL) Non‐covered; Influenza virus vaccine, derived from cell cultures, subunit, No FDA 90661 preservative and antibiotic free, for intramuscular use approval Influenza virus vaccine, split virus, preservative free, enhanced Non‐covered; immunogenicity via increased antigen content, for intramuscular No FDA 90662 use approval 90663 Influenza virus vaccine, pandemic formulation Influenza virus vaccine, pandemic formulation, live, for intranasal 90664 use Lyme disease vaccine, adult dosage, for intramuscular use. 90665 (30mcg/0.5ml) (All NDC's are inactive) Influenza virus vaccine, pandemic formulation, preservative free, for 90666 intramuscular use Influenza virus vaccine, pandemic formulation, split virus, 90667 adjuvanted, for intramuscular use Influenza virus vaccine, pandemic formulation, split virus, for 90668 intramuscular use This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider. Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the most recent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accrediting organization guidelines and requirements, including NCQA. Origination Date – 5/3/2005 BMC HealthNet Plan – CPT/HCPCS Medication Code Reference List 3 of 35 Prior Authorization Code Description Required Pneumococcal conjugate vaccine, 7 valent, for intramuscular use 90669 (Code Price is per 0.5 mL dose) 90675 Rabies vaccine, for intramuscular use.(Code price is per 1 mL) Rabies vaccine, for intradermal use (Code Price is per 0.1 90676 mL)(Product not available) 90680 Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use Rotavirus vaccine, human, attenuated, 2 dose schedule, live, for oral 90681 use Typhoid vaccine, live, oral (Code Price is based one course of 90690 therapy = 4 capsules) Typhoid vaccine, Vi capsular polysaccharide (ViCPs), for 90691 intramuscular use. (Code price is per 0.5 mL) Typhoid vaccine, heat‐ and phenol‐inactivated (HP), for subcutaneous or intradermal use. (Code Price is per 0.5 mL)(Product 90692 not available) Typhoid vaccine, acetone‐killed, dried (AKD), for subcutaneous use 90693 (U.S. military) Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine, inactivated (DTaP‐IPV), when administered to 90696 children 4 through 6 years of age, for intramuscular use Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza Type B, and poliovirus vaccine, inactivated (DTaP‐Hib‐ 90698 IPV), for intramuscular use Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), for use in individuals younger than seven years, for intramuscular 90700 use (Code price is per 0.5 mL dose) Diphtheria, tetanus toxoids, and whole cell pertussis vaccine (DTP), 90701 for intramuscular use Diphtheria and tetanus toxoids (DT) adsorbed, for use in individuals younger than 7 years, for intramuscular use.(Code price is per 0.5 90702 mL) Tetanus toxoid adsorbed, for intramuscular use (Code Price is per 90703 0.5 mL) This guideline provides information on BMC HealthNet Plan claims adjudication processing guidelines. The use of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement is based on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Plan policies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing