VFC Public Clinic CPT Code CVX NDC PRESENTATION ...

[Pages:2]PUBLIC HEALTH DIVISION Immunization Program

State-Supplied Vaccine Billing Codes

Last Updated: August 10, 2022

ICD-10 code for all routine immunizations is Z23

CPT Code CVX

NDC

ANTIGEN(S)

BRAND NAME

VFC COVERED?

90702

28 Single Dose Vial, 10 Pack 49281-0225-10

DT; diphtheria and tetanus toxoids, adsorbed, for use in individuals younger than 7 years, for intramuscular use

Diphtheria and Tetanus Toxoids Adsorbed (no

brand name)

Yes

DTaP; diphtheria, tetanus toxoids,

90700

20

Infanrix Syringes, 10 Pack 58160-0810-52

and acellular pertussis vaccine for use in individuals younger than seven

Infanrix

Yes

years, for intramuscular use

DTaP; diphtheria, tetanus toxoids,

90700

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

and acellular pertussis vacine for use in individuals younger than seven

DAPTACEL

Yes

years, for intramuscular use

DTaP-Hep B-IPV; diphtheria, tetanus

90723

110 Syringes, 10 Pack 58160-0811-52

toxoids, acellular pertussis, hepatitis

Pediarix

Yes

B, inactivated polio virus vaccine

90698

90696

90697 90632 90633 90636

120 Single Dose Vial, 5 Pack 49281-0511-05

DTaP-Hib-IPV; diphtheria, tetanus toxoids, acellular pertussis,

haemophilus influenza type B, inactivated polio virus vaccine

Dtap-IPV; combined

130

Quadracel Multi-dose Vial 49281-0562-10 Quadracel Syringes, 10 Pack 49281-056415 Kinrix Syringes, 10 Pack 58160-0812-52

Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine, inactivated, when administered to children 4 years through 6 years of age, for

intramuscular use

DTaP-IPV-Hib-HepB; diphtheria,

tetanus toxoids, acellular pertussis

146

Pre-filled syringes, 10 Pack 63361-243-15 Multidose Vial, 63361-0243-10

vaccine, inactivated poliovirus vaccine, Haemophilus influenzae type

b PRP-OMP conjugate vaccine, and

hepatitis B vaccine, for intramuscular

use

Havrix Syringes, 10 Pack 58160-0826-52 52 Vaqta Single Dose Vial, 10 Pack 00006-4096-

02

Hepatitis A, adult dosage

83

Havrix Syringes, 10 Pack 58160-0825-52 Vaqta Syringes, 10 Pack 00006-4095-02

Hepatitis A, pediatric/adolescent, 2 dose series

104 Syringes, 10 Pack 58160-0815-52

HepA-HepB; Hepatitis A, Hepatitis B Adult, 3 dose series

Pentacel

Kinrix; Quadracel

Vaxelis Havrix; Vaqta Havrix; Vaqta

Twinrix

Yes

Yes

Yes Age 18 only

Yes Age 18 only

Recombivax Single Dose Vial, 10 Pack

90744

08

00006-4981-00 Recombivax Syringes, 10 Pack 00006-409302

Hepatitis B pediatric/adolescent, 3 dose series

Recombivax HB; EngerixB

Yes

Engerix-B Syringes, 10 Pack 58160-0820-52

317 Adults Covered?

No No No No No

No

No

Yes No Yes No

Public Clinic "Billables"?

Yes Yes Yes Yes Yes

Yes

Yes

Yes Yes Yes Yes

CPT Code

90746

90739 90759 90647 90648

90651 90713 90734 90619 90734

90621

CVX

NDC

ANTIGEN(S)

Recombivax Single Dose Vial, 10 Pack 00006-4995-41

43

Hepatitis B, adult dosage for IM use,

Engerix-B Single Dose Vial, 10 Pack 58160-

3 dose series

0821-11

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

189 Single Dose Vial, 5 pack 43528-0003-05

Hepatitis B Vaccine, Recombinant, Adjuvanted, adult dosage

220

Single Dose Vial, 10-pack 75052-0001-10

Hepatitis B Vaccine, Recombinant, 3antigen, Al(OH)3

49 Single Dose Vial, 10 Pack 00006-4897-00

Hib, PRP-OMP conjugate, 3 dose series

ActHib Single Dose Vial, 5 Pack 49281-0545-

48

03 Hiberix Single Dose Vial, 10 Pack 58160-

Hib, PRP-T conjugate, 4 dose series

0818-11

HPV; human Papillomavirus vaccine

165 Syringes, 10 Pack 00006-4121-02

types 6, 11, 16, 18, 31, 33, 45, 52,

58, nonavalent

10 Multi-dose Vial, 49281-0860-10

IPV; Poliovirus, Inactivated

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

Meningococcal Conjugate A,C,Y, W135

203 Single Dose Vial, 5 Pack 49281-0590-05

Meningococcal Conjugate A,C,Y, W

136 Single Dose Vial, 5 Pack 58160-0955-09

Meningococcal Conjugate A,C,Y, W135

Syringes, 10 Pack 00005-0100-10 162

Syringes, 5 Pack 00005-0100-05

Meningococcal recombinant lipoprotein vaccine, serogroup B, 3 dose schedule, for intramuscular use

90620

90707 90707 90710

90732

90670 90671 90677 90681

163 Syringes, 10 Pack 58160-0796-20

Meningococcal recombinant protein and outer membrane vesicle vaccine,

serogroup B, 2 dose schedule, for intramuscular use

03 Single Dose Vial, 10 Pack 00006-4681-00 03 Single Dose Vial, 10 Pack 58160-0824-15

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

Syringe, 10 Pack 00006-4943-03 33

Single Dose Vials, 10 Pack 00006-4943-00

MMR; Measles, Mumps, Rubella MMR; Measles, Mumps, Rubella MMRV; Measles, Mumps, Rubella,

Varicella

PPSV23; pneumococcal polysaccharide, 23 valent

Syringe, 10 Pack 00005-1971-02 133

Syringe, 1 Pack 00005-1971-05 215 Syringe, 10 Pack 00006-4329-03 216 Syringe, 10 Pack 00005-2000-10

PCV13; pneumococcal conjugate vaccine, 13 valent

PCV15; pneumococcal conjugate, 15 valent

PCV20; pneumococcal conjugate vaccine, 20 valent

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

Rotavirus

90680

116

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

Rotavirus

BRAND NAME

Recombivax HB; Engerix-B

Heplisav-B PreHevbrio PedvaxHIB

ActHIB; Hiberix

Gardasil 9 IPOL

Menactra MenQuadfi

Menveo

Trumenba

Bexsero MMRII Priorix PROQUAD Pneumovax 23

Prevnar13 Vaxneuvance

Prevnar 20 Rotarix

ROTATEQ

VFC COVERED?

No

317 Adults Covered?

No

Age 18 only

Yes

Age 18 only

Yes

No

No

Yes

Yes

Yes

Yes

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

No

No

Yes

Yes Coming Soon

Yes Yes No Yes No No No Yes

Yes

No

Some Some, Coming Soon

No Yes No No No Yes Yes No

No

Public Clinic "Billables"?

No

Yes

Yes No Yes

Yes

Yes Yes Yes Yes Yes Yes No

Yes

Yes Coming Soon

Yes Yes No Yes No Yes Yes Yes

Yes

CPT Code CVX

NDC

ANTIGEN(S)

90715

Adacel Single Dose Vial, 10 Pack 49281-

115

0400-20 Boostrix Single Dose Vial, 10 Pack 581600842-11

Tdap; tetanus, diphtheria toxoids and acellular pertussis vaccine

Boostrix Syringes, 10 Pack 58160-0842-52

90714 90716 90611

90750

Tenivac Single Dose Vial, 1 Pack 492810215-10 113 Tenivac Syringes, 10 Pack 49281-0215-15 TDVAX Single Dose Vial, 10 Pack 1353300131-01

Td; preservative-free tetanus and diphtheria toxoids

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

Varicella

Vaccinia, smallpox monkeypox

206

Single Dose Vial, 20 Pack 50632-0001-01 vaccine, live attenuated, preservative

free

2 Components, Single Dose 58160-0819-12

2 Components, Multidose Vial 58160-0823187 11

Zoster Vaccine Recombinant, Adjuvanted

BRAND NAME

Adacel; Boostrix

Tenivac; TDVAX Varivax Jynneos Shingrix

VFC COVERED?

Yes

Yes Yes No No No

317 Adults Covered?

Yes

Yes Some

Yes No No

Public Clinic "Billables"?

Yes

Yes Yes No Yes Yes

CPT Code

CVX

90634 84

90645 47

NDC

90646 46

90654

144

Microinjection System, 10 Pack 49281-709-55

90655 140

Influenza virus vaccine, split virus, preservative free, for use 90655 140 in individuals 6-35 months of

age, for intramuscular use trivalent

HISTORICAL ONLY

ANTIGEN(S)

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

Hib, PRP-D conjugate, booster dose only

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

Influenza virus vaccine, split virus, preservative free, for use in individuals 6-35 months of age, for intramuscular use - trivalent

preservative-free, pediatric

BRAND NAME

Havrix; Vaqta HibTITTER

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

Comments

(no longer on the market)

(no longer on the market)

Trivalent no longer being used

Trivalent no longer being used

Trivalent no longer being used

Trivalent no longer being used

Trivalent no longer being used

66019-1019-01

90661

153

1 dose syringe, 10 pack 625770614-01

90672 149 66019-0302-10

90703 35 90704 07 90705 05 90706 06 90708 04

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

Influenza virus vaccine, quadrivalent, live, for intranasal use

Tetanus toxoid absorbed Mumps virus vaccine Measles virus vaccine

Rubella virus vaccine, live Measles and rubella virus vaccine

Flucelvax

FluMist Quadrivalent

Trivalent no longer being used

Currently not recommended for use

in 2016-17 season

CPT Code

CVX

NDC

90718 09

90719

90720

90735 90738

N/A

22

49281-680-30 134

49281-562-58

ANTIGEN(S)

BRAND NAME

Diphteria and

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

individuals 7 years or older, for intramuscular use Absorbed for Adults

Use

Diphtheria toxoid

Diphtheria, tetanus toxoids, whole cell pertussis and Hib

Tetramune

Japanese Encephalitis

JE-VAX

Japanese encephalitis virus vaccine, inactivated

Ixiaro

Diphtheria, tetanus, pertussis and polio

Quadracel

58160-830-34; 58160-830-52

HPV2

Cervarix

153

1 dose syringe, 10 pack 625770614-01

144 49281-0709-55

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

Influenza, split virus, preservative-free, intradermal trivalent

Flucelvax Fluzone ID

90748

51

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

Hepatitis B and Hib

Comvax

Comments

Trivalent no longer being used

Trivalent no longer being used

No longer on the market

90630 166 10 single dose microinjectors

90673 155 10 single dose vials 90656 140 10 pre-filled syringes

seasonal influenza, quadrivalent, intradermal, preservative free

Fluzone Intradermal Quadrivalent

seasonal

influenza, trivalent, derived from DNA, preservative free

recombinant

Flublok

Trivalent

seasonal influenza, trivalent, preservative free

Fluvirin Trivalent

90658 141 multi-dose vial, 5 mL

seasonal influenza, trivalent, with preservative

Fluvirin Trivalent

90650 90736 90685

118

Syringes, 10 pack 58160-083052

121

Single Dose Vial, 1 Pack 000064963-41

161

0.25 mL 10 pre-filled syringes; 33332-0221-20

Human Papilloma virus (HPV), types 16, 18 (bivalent) Zoster Vaccine Live

seasonal influenza, quadrivalent, preservative free

90688 158

multi-dose vial, 5 mL; 19515-0897-11

seasonal influenza, quadrivalent, with preservative

Cervarix

Zostavax

AFLURIA Quadrivalent

FluLaval Quadrivalent

No longer on the market

Trivalent no longer being used

Trivalent no longer being used

Trivalent no longer being used

No longer on the market.

No longer on the market

0.25mL PFS no longer on the market

Multidose vial no longer on the market

CPT Code

CVX

NDC

ANTIGEN(S)

BRAND NAME

Comments

90685

161

0.25 mL 10 pre-filled syringes; 49281-0519-25

seasonal influenza, quadrivalent, preservative free

Fluzone Quadrivalent

0.25mL PFS no longer on the market

ActHib Single Dose Vial, 5 Pack 90648 48 49281-0545-05

Hib, PRP-T conjugate, 4 dose series

ActHIB

This NDC no longer on the market

Adacel Syringes, 5 Pack 4928190715 115 0400-15

Tetanus, diphtheria toxoids and acellular pertussis vaccine (TdaP)

Adacel; Boostrix

This NDC no longer on the market

90620 90702 90651 90632 90744

163

Syringes, 1 Pack 58160-079606

Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B, 2 dose

schedule, for intramuscular

Single Dose Vial, 1 Pack 49281- Diphtheria and tetanus toxoids, (DT), absorbed for use

28 0278-10

in individuals younger than 7 years, for intramuscular

use.

Single Dose Vial, 1 Pack 00006-

165

4119-02

Human Papillomavirus vaccine types 6, 11, 16, 18, 31,

Single Dose Vial, 10 Pack 00006-

33, 45, 52, 58, nonavalent (HPV)

4119-03

Havrix Single Dose Vial, 10 Pack

52

58160-0826-11 Vaqta Single Dose Vial, 10 Pack

Hepatitis A, adult dosage

00006-4841-41

Engerix-B Single Dose Vial, 10

08 Pack 58160-0820-11

Hepatitis B pediatric/adolescent, 3 dose series

Bexsero Diphteria and Tetanus Toxoids

Absorbed

Gardasil 9

Havrix; Vaqta

Recombivax HB; Engerix-B

This NDC no longer on the market

This NDC no longer on the market

This NDC no longer on the market

This NDC no longer on the market

This NDC no longer on the market

Recombivax Single Dose Vial, 1 90746 43 Pack 00006-4995-00

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

Recombivax HB

This NDC no longer on the market

90633

Havrix Single Dose Vial, 10 Pack 58160-0825-11 83 Vaqta Single Dose Vial, 10 Pack 00006-4831-41

Hepatitis A, pediatric/adolescent, 2 dose series

Havrix; Vaqta

This NDC no longer on the market

90739 90700

189

Single Dose Vial, 5 pack 435280002-05

Hepatitis B Vaccine, Recombinant, Adjuvanted, adult dosage

20

Infanrix Single Dose Vial, 10 Pack 58160-0810-11

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

years, for intramuscular use.

Heplisav-B Infanrix

This NDC no longer on the market

This NDC no longer on the market

CPT Code

90696

90733 90734 90698

CVX

NDC

Kinrix Single Dose Vial, 10 Pack 130 58160-0812-11

32

Single Dose Vial, 1 Pack 492810489-01

136

Single Dose Vial, 5 Pack 460280208-01

120

Single Dose Vial, 5 Pack 492810510-05

ANTIGEN(S)

Dtap/IPV combined Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine, inactivated (DTaP-IPV), when

administered to children 4 years through 6 years of age, for intramuscular use

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

Meningococcal Conjugate A,C,Y, W-135

Diphtheria, tetanus toxoids, acellular pertussis, haemophilus influenza type B, inactivated polio virus

vaccine (DTap, Hib, IPV)

BRAND NAME

Kinrix

Menomune Menveo Pentacel

90732 90636 90736

33 Multi-dose Vial 00006-4739-00

104

Single Dose Vial, 10 Pack 581600815-11

121

Single Dose Vial, 1 Pack 000064963-41

Pneumococcal polysaccharide, 23 valent Hepatitis A, Hepatitis B Adult, 3 dose series

Zoster Vaccine Live

Pneumovax 23 Twinrix Zostavax

Comments

This NDC no longer on the market

This vaccine is no longer on the market This NDC no longer on

the market This NDC no longer on

the market

This NDC no longer on the market

This NDC no longer on the market

This vaccine no longer on the market

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