Commonly Administered Pediatric Vaccines

1 Effective 1/1/2016 Commonly Administered Pediatric Vaccines CPT Separately report the administration with Current Procedural Terminology (CPT ). # of Vaccine Product codes 90460- 90461 or 90471-90474 [Please see table below] Manufacturer Brand Components Code Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B, 2 dose Novartis Bexsero 90620 1. schedule, for IM use 90621 Meningococcal recombinant lipoprotein vaccine, serogroup B, 3 dose schedule, for IM use Pfizer Trumenba 1. Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use Sanofi Pasteur Fluzone Intradermal 90630 1.

2 Quadrivalent Hepatitis A vaccine(Hep A), Pediatric /adolescent dosage, 2 dose, for IM use GlaxoSmithKline HAVRIX. 90633 1. Merck VAQTA. Meningococcal conjugate vaccine, serogroups C & Y and Hemophilus influenza B vaccine 90644 (MenCY-Hib), 4-dose schedule, when Administered to children 6 weeks 18 months of age, for GlaxoSmithKline MenHibrix 2. IM use 90647 Hemophilus influenza B vaccine (Hib), PRP-OMP conjugate, 3 dose, for IM use Merck PedvaxHIB 1. Hemophilus influenza B vaccine (Hib), PRP-T conjugate, 4 dose, for IM use sanofi pasteur ActHIB.

3 90648 1. GlaxoSmithKline HIBERIX. Human Papilloma virus vaccine, types 6, 11, 16, 18 quadrivalent (HPV4), 3 dose schedule, for Merck GARDASIL. 90649 1. IM use 90650 Human Papilloma virus vaccine, types 16 and 18, bivalent (HPV2), 3 dose schedule, for IM use GlaxoSmithKline CERVARIX 1. Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (HPV), 3 dose Merck GARDASIL 9. 90651 1. schedule, for IM use Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, for children 6-35 months of sanofi pasteur Fluzone No Preservative 90655.

4 Age, for IM use Pediatric 1. Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, when Administered to 3 Merck AFLURIA. years of age and above, for IM use sanofi pasteur Fluzone No Preservative 90656 Novatis Fluvirin 1. GlaxoSmithKline FLUARIX. GlaxoSmithKline FLULAVAL. 90657 Influenza virus vaccine, trivalent (IIV3), split virus, 6 35 months dosage, for IM use Sanofi Pasteur Fluzone 1. Influenza virus vaccine, trivalent (IIV3), split virus, 3 years and older dosage, for IM use Merck AFLURIA. GlaxoSmithKline FLULAVAL.

5 90658 1. sanofi pasteur Fluzone Novartis Fluvirin 90670 Pneumococcal conjugate vaccine, 13 valent (PCV13), for IM use Pfizer PREVNAR 13 1. 90672 Influenza virus vaccine, quadrivalent (LAIV), live, intranasal use MedImmune Flumist Quadrivalent 1. 90680 Rotavirus vaccine, pentavalent (RV5), 3 dose schedule, live, for oral use Merck RotaTeq 1. 90681 Rotavirus vaccine, human, attenuated (RV1), 2 dose schedule, live, for oral use GlaxoSmithKline ROTARIX 1. Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for children 6-35 months 90685 1.

6 Of age, for IM use Sanofi Pasteur Fluzone Quadrivalent Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, when Administered to 3 Sanofi Pasteur Fluzone Quadrivalent 90686 1. years of age and above, for IM use GlaxoSmithKline FLUARIX Quadrivalent 90687 Influenza virus vaccine, quadrivalent (IIV4), split virus, 6 35 months dosage, for IM use Sanofi Pasteur Fluzone Quadrivalent 1. Influenza virus vaccine, quadrivalent (IIV4), split virus, 3 years and older dosage, for IM use Sanofi Pasteur Fluzone Quadrivalent 90688 1.

7 GlaxoSmithKline FLULAVAL. Diphtheria, tetanus toxoids, and acellular pertussis vaccine and inactivated poliovirus vaccine 90696. (DTaP-IPV), when Administered to children 4 years through 6 years of age, for IM use GlaxoSmithKline KINRIX 4. Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, . 90697 Haemophilus influenza type b PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV- 6. Hib-HepB), for IM use Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza Type B, and sanofi pasteur Pentacel 90698 5.

8 Inactivated poliovirus vaccine (DTaP -IPV/Hib), for IM use Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when Administered to sanofi pasteur DAPTACEL. 90700. younger than seven years, for IM use GlaxoSmithKline INFANRIX 3. CPT . Separately report the administration with codes 90460- 90461 or 90471-90474 # of Vaccine Product Manufacturer Brand [Please see table below] Components Code Diphtheria and tetanus toxoids (DT), adsorbed when Administered to younger than seven Diphtheria and Tetanus 90702. years, for IM use sanofi pasteur Toxoids Adsorbed 2.

9 90707 Measles, mumps, and rubella virus vaccine (MMR), live, for subcutaneous use Merck M-M-R II 3. 90710 Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use Merck ProQuad 4. 90713 Poliovirus vaccine (IPV), inactivated, for subcutaneous or IM use sanofi pasteur IPOL 1. Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, when Administered to seven 90714 sanofi pasteur TENIVAC 2. years or older, for IM use Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when Administered to 7 sanofi pasteur ADACEL.

10 90715 3. years or older, for IM use GlaxoSmithKline BOOSTRIX. 90716 Varicella virus vaccine (VAR), live, for subcutaneous use Merck VARIVAX 1. Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and inactivated poliovirus 90723 GlaxoSmithKline PEDIARIX 5. vaccine (DTaP-Hep B-IPV), for IM use Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed 90732 Merck PNEUMOVAX 23 1. patient dosage, when Administered to 2 years or older, for subcutaneous or IM use Meningococcal polysaccharide vaccine, serogroups A, C, Y, W-135, quadrivalent (MenACWY.)