State Supplied Vaccine Billing Codes Last Updated: July 31 ...

PUBLIC HEALTH DIVISION Immunization Program

CPT Code CVX

NDC

State Supplied Vaccine Billing Codes

Last Updated: July 31, 2019

ICD-10 code for all immunizations is Z23

ANTIGEN(S)

BRAND NAME

VFC COVERED?

90648

90715

90620 90700 90714 90702 90651 90632

90633 90739 90700 90713

48 Single Dose Vial, 5 Pack 49281-0545-05

Hib, PRP-T conjugate, 4 dose series

ActHIB

Yes

Adacel Single Dose Vial, 10 Pack 49281-

0400-10

115

Adacel Syringes, 5 Pack 49281-0400-15 Boostrix Single Dose Vial, 10 Pack 58160-

0842-11

Boostrix Syringes, 10 Pack 58160-0842-52

Tetanus, diphtheria toxoids and acellular pertussis vaccine (TdaP)

Adacel; Boostrix

163

Syringes, 1 Pack 58160-0796-06 Syringes, 10 Pack 58160-0796-20

106 Single Dose Vial, 10 Pack 49281-0286-10

Meningococcal recombinant protein and outer membrane vesicle vaccine,

serogroup B, 2 dose schedule, for intramuscular

Diphtheria, tetanus toxoids, and acellular pertussis vacine (DTaP) for use in individuals younger than seven

years, for intramuscular use.

Bexsero DAPTACEL

Tenivac Single Dose Vial, 1 Pack 49281113 0215-10

Tenivac Syringes, 10 Pack 49281-0215-15

Preservative-free tetanus and diphtheria toxoids (Td)

Decavac; Tenivac

Diphtheria and tetanus toxoids, (DT),

28

Single Dose Vial, 1 Pack 49281-0278-10 Single Dose Vial, 10 Pack 49281-0225-10

absorbed for use in individuals younger than 7 years, for

Diphteria and Tetanus Toxoids Absorbed

intramuscular use.

Single Dose Vial, 1 Pack 00006-4119-02 165 Single Dose Vial, 10 Pack 00006-4119-03

Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58,

Gardasil 9

Syringes, 10 Pack 00006-4121-02

nonavalent (HPV)

Havrix Single Dose Vial, 10 Pack 58160-

0826-11 52 Havrix Syringes, 10 Pack 58160-0826-52

Hepatitis A, adult dosage

Havrix; Vaqta

Vaqta Single Dose Vial, 10 Pack 00006-4841-

41

Havrix Single Dose Vial, 10 Pack 58160-

0825-11

83

Havrix Syringes, 10 Pack 58160-0825-52

Hepatitis A, pediatric/adolescent, 2

Vaqta Single Dose Vial, 10 Pack 00006-4831-

dose series

Havrix; Vaqta

41

Vaqta Syringes, 10 Pack 00006-4095-02

189 Single Dose Vial, 5 pack 43528-0002-05

Hepatitis B Vaccine, Recombinant, Adjuvanted

Heplisav-B

20

Infanrix Single Dose Vial, 10 Pack 581600810-11 Infanrix Syringes, 10 Pack 58160-0810-52

Diphtheria, tetanus toxoids, and acellular pertussis vacine (DTaP) for use in individuals younger than seven

years, for intramuscular use.

Infanrix

Yes

Yes Yes Yes Yes Yes Age 18 only

Yes Soon (Age 18 only)

Yes

10 Multi-dose Vial 49281-0860-10

Poliovirus, Inactivated, IPV

IPOL

Yes

Dtap/IPV combined

90696

130

Quadracel Multi-dose Vial 49281-0562-10 Kinrix Single Dose Vial, 10 Pack 58160-081211 Kinrix Syringes, 10 Pack 58160-0812-52

Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus

vaccine, inactivated (DTaP-IPV), when administered to children 4 years through 6 years of age, for

Kinrix; Quadracel

Yes

intramuscular use

317 Adults Covered?

Yes

Yes

No No Yes No No Yes

No No No No

No

Public Clinic "Billables"?

Yes

Yes

Yes Yes Yes Yes Yes Yes

Yes Soon Yes Yes

Yes

Page 1 of 5



CPT Code CVX

NDC

ANTIGEN(S)

BRAND NAME

VFC COVERED?

90734 90733 90734 90707 90723 90647 90698 90732 90670 90710

90744

90746

90681 90680

90750 90621 90636 90716 90736

114 Single Dose Vial, 5 Pack 49281-0589-05

Meningococcal Conjugate A,C,Y, W135

Menactra

32 Single Dose Vial, 1 Pack 49281-0489-01

136 Single Dose Vial, 5 Pack 46028-0208-01 03 Single Dose Vial, 10 Pack 00006-4681-00 110 Syringes, 10 Pack 58160-0811-52 49 Single Dose Vial, 10 Pack 00006-4897-00

120 Single Dose Vial, 5 Pack 49281-0510-05

33

Single Dose Vial, 10 Pack 00006-4943-00 Multi-dose Vial 00006-4739-00

133

Single Dose Vial, 10 Pack 00005-1971-02 Single Dose Vial, 1 Pack 00005-1971-05

Meningococcal Polysaccharide, A, C, Y, W-135

Meningococcal Conjugate A,C,Y, W136

Measles, Mumps, Rubella DTaP, Hepatitis B, IPV

Hib, PRP-OMP conjugate, 3 dose series

Diphtheria, tetanus toxoids, acellular pertussis, haemophilus influenza type

B, inactivated polio virus vaccine (DTap, Hib, IPV)

Pneumococcal polysaccharide, 23 valent

Pneumococcal conjugate vaccine, 13 valent

Menomune Menveo MMRII Pediarix

PedvaxHIB

Pentacel

Pneumovax 23 Prevnar13

94 Single Dose Vial, 10 Pack 00006-4171-00

MMRV

PROQUAD

Recombivax Single Dose Vial, 10 Pack

08

00006-4981-00

Hepatitis B pediatric/adolescent, 3 Recombivax HB; Engerix-

Recombivax Syringes, 10 Pack 00006-4093-

dose series

B

02

Recombivax Single Dose Vial, 10 Pack

00006-4995-41

43

Recombivax Single Dose Vial, 1 Pack 000064995-00 Engerix-B Single Dose Vial, 10 Pack 58160-

Hepatitis B, adult dosage for IM use, 3 dose series

Recombivax HB; EngerixB

0821-11

Engerix-B Syringes, 10 Pack 58160-0821-52

119 Single Dose Vial, 10 Pack 58160-0854-52

Rotavirus

Rotarix

116

Single Dose Tubes, 10 Pack 00006-4047-41 Single Dose Tubes, 25 Pack 00006-4047-20

Rotavirus

ROTATEQ

187 2 Components, Single Dose 58160-0819-12

Zoster Vaccine Recombinant, Adjuvanted

162

Syringes, 5 Pack 00005-0100-05 Syringes, 10 Pack 00005-0100-10

104

Single Dose Vial, 10 Pack 58160-0815-11 Syringes, 10 Pack 58160-0815-52

Meningococcal recombinant lipoprotein vaccine, serogroup B, 3 HdoespeatsitcihseAd,uHleepfaotritiinstrBamAduuslctu, l3arduossee

series

21 Single Dose Vial, 10 Pack 00006-4827-00

Varicella

Shingrix Trumenba

Twinrix Varivax

121 Single Dose Vial, 1 Pack 00006-4963-41

Zoster Vaccine Live

Zostavax

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Yes

Age 18 only

Yes Yes

No Yes Age 18 only Yes No

317 Adults Covered?

No

No No Some No Yes No Yes Yes No

No

Yes

No No

No No Yes Some No

State Supplied Vaccine Billing Codes Public Clinic "Billables"? Yes

Yes Yes Yes Yes Yes Yes Yes Yes Yes

Yes

Yes

Yes Yes

Soon Yes Yes Yes No

2 of 5



CPT Code

90686 90688 90687 90685 90653 90686 90682 90756 90674 90686 90688 90672 90662 90685

90686

90687 90688

CVX

150 158 158 161 168 150 185 186 171 150 158 149 135 161

150

158 158

Influenza Vaccines 2019-2020 Season

NDC

33332-0319-01 33332-0419-10 33332-0419-10 33332-0219-20 70461-0019-03 58160-0896-52 49281-0719-10 70461-0419-10 70461-0319-03 19515-0906-52 19515-0897-11 66019-0306-10 49281-0405-65 49281-0519-25 49281-0419-50 49281-0419-10 49281- 0631-15 49281-0631-15

PRESENTATION

0.5 mL 10 pre-filled syringes

DESCRIPTION

seasonal influenza, quadrivalent,

preservative free

multi-dose vial, 5 mL (0.5 mL dose)

seasonal influenza, quadrivalent, with

preservative

multi-dose vial, 5 mL (0.25 mL dose)

seasonal influenza, quadrivalent, with

preservative

0.25 mL 10 pre-filled syringes

seasonal influenza, quadrivalent,

preservative free

10 pre-filled syringes

seasonal influenza, adjuvanted,

preservative free

10 pre-filled syringes

seasonal influenza, quadrivalent,

preservative free

10 pre-filled syringes

seasonal influenza, quadrivalent, derived from recombinant DNA,

preservative free

multi-dose vial, 5 mL

seasonal influenza, quadrivalent, MDCK, contains preservative

10 pre-filled syringes

seasonal influenza, quadrivalent, MDCK,

preservative free

10 pre-filled syringes

seasonal influenza, quadrivalent,

preservative free

multi-dose vial, 5 mL

seasonal influenza, quadrivalent, with

preservative

BRAND NAME

AFLURIA Quadrivalent

FLUAD Trivalent Fluarix Quadrivalent Flublok Quadrivalent Flucelvax Quadrivalent Flucelvax Quadrivalent FluLaval Quadrivalent

VFC COVERED?

317 Adults Covered?

Public Clinic "Billables"?

No

No

No

No

No

No

Yes

No

No

No

No

No

Yes

No

No

Yes

No

No

Yes

Special Project Only (with advance approval)

No

Yes

No

10 single dose sprayers

seasonal influenza, liveattenuated, intranasal,

quadrivalent

FluMist Quadrivalent

Yes

Special Project Only (with advance approval)

No

10 pre-filled syringes

seasonal influenza, trivalent, high-dose

Fluzone High Dose

No

No

No

seasonal influenza,

0.25 mL 10 pre-filled syringes

quadrivalent,

Fluzone Quadrivalent

Yes

No

No

preservative free

0.5 mL 10 pre-filled syringes

seasonal influenza, quadrivalent,

preservative free

Yes

Special Project Only (with advance approval)

No

Fluzone Quadrivalent

seasonal influenza,

0.5 mL 10 single dose vials

quadrivalent,

Yes

No

No

preservative free

seasonal influenza,

Fluzone Quadrivalent

multi-dose vial, 5 mL

quadrivalent, with Multidose Vials (0.25 mL

Yes

No

No

preservative

dose)

seasonal influenza,

Fluzone Quadrivalent

multi-dose vial, 5 mL

quadrivalent, with

Multidose Vials (0.5 mL

Yes

No

No

preservative

dose)

CPT Code

CVX

90634 84

90645 47

NDC

HISTORICAL ONLY

ANTIGEN(S)

Hepatitis A, 3 dose series Hib, HbOC conjugate, 4 dose series

BRAND NAME

Havrix; Vaqta HibTITTER

90646 90654 90655

90655

46

Hib, PRP-D conjugate, booster dose only

144

Microinjection System, 10 Pack 49281-709-55

Influenza virus vaccine, split virus, preservative free, for intradermal use - trivalent

Influenza virus vaccine, split virus, preservative free,

140

for use in individuals 6-35 months of age, for

intramuscular use - trivalent

Influenza virus vaccine, split

virus, preservative free, for use

140 in individuals 6-35 months of

preservative-free, pediatric

age, for intramuscular use -

trivalent

ProHibit (no longer on market) Fluzone, intradermal Fluzone,

preservative-free, pediatric

Fluzone

90657

141

Fluzone Multi-dose Vial 492810396-15

Influenza virus vaccine, split virus - trivalent - when given as a 0.25mL dose

Fluzone Trivalent Multidose Vials

90660

66019-0108-10 - 10 prefilled,

single-use sprayers

111

66019-0107-01 - 10 prefilled, single-use sprayers

Influenza virus vaccine, live, for intranasal use trivalent

Flumist

66019-1019-01

90661

153

1 dose syringe, 10 pack 625770614-01

Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use - trivalent

90672 149 66019-0302-10

Influenza virus vaccine, quadrivalent, live, for intranasal use

90703 35 90704 07 90705 05 90706 06 90708 04

Tetanus toxoid absorbed Mumps virus vaccine Measles virus vaccine Rubella virus vaccine, live Measles and rubella virus vaccine

Flucelvax

FluMist Quadrivalent

90718

90719 90720 90735 90738

Diphteria and

09

Tetanus and diphteria toxoids (TD) absorbed for use in Tetanus Toxoids

individuals 7 years or older, for intramuscular use

Absorbed for Adults

Use

N/A

Diphtheria toxoid

22

Diphtheria, tetanus toxoids, whole cell pertussis and Hib

Tetramune

49281-680-30

Japanese Encephalitis

JE-VAX

134

Japanese encephalitis virus vaccine, inactivated

Ixiaro

49281-562-58

Diphtheria, tetanus, pertussis and polio

Quadracel

58160-830-34; 58160-830-52 HPV2

Cervarix

153

1 dose syringe, 10 pack 625770614-01

Influenza virus vaccine, split virus, preservative-free, for intramuscular use - trivalent - 18+ years

Flucelvax

144 49281-0709-55

Influenza, split virus, preservative-free, intradermal trivalent

Fluzone ID

90748

51

Single Dose Vial, 10 Pack 000064898-00 (discontinued)

Hepatitis B and Hib

Comvax

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