Changes in coverage of select Vaccines for CHP, FHP, and NYM members Covered without restrictions (Rabies vaccine) (Rabies vaccine)

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1 Changes in coverage of select Vaccines for CHP, FHP, and NYM members Please note that effective 2/1/2012 Fidelis Care is implementing the following changes for covering select CPT vaccine codes listed below (just as a reminder - 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 reimbursed under VFC program): Covered without restrictions (Rabies vaccine) Covered for all age groups and all lines of business (LOBs) without restrictions (Rabies vaccine) Covered for all age groups and all LOBs without restrictions Covered with prior authorization (Typhoid vaccine) Covered with prior authorization for all ages and LOBs (Typhoid vaccine) Covered with prior authorization for all ages and LOBs (Typhoid vaccine) Covered with prior authorization for all ages and LOBs (Typhoid vaccine) Covered with prior authorization for all ages and LOBs (Cholera vaccine) Covered with prior authorization for all ages and LOBs (Plague vaccine) Covered with prior authorization for all ages and LOBs (Japanese encephalitis virus vaccine) Covered with prior authorization for all ages and LOBs (Yellow fever vaccine) Covered with prior authorization for all ages and LOBs (Dtap-IPV) Covered with prior authorization for adults 19 years of age for all LOBs (Dtap-IPV and Haemophilus influenza type b) Covered with prior authorization for adults 19 years of age for all LOBs Covered with age restrictions (Human Papillomavirus vaccine) Covered only for ages 19 years of age through 26 years of age for all LOBs (Human Papillomavirus vaccine)- Covered only for females > 19 yo through < (DTP) Covered for adults 19 years of age for all LOBs (Tetanus Toxoid) Covered for ages 7 years of age for all LOBs (Hepatitis B vaccine) Covered for adults 19 years of age for all LOBs (Tetanus and diphtheria toxoids) Covered for adults 19 years of age for all LOBs (Hepatitis B vaccine) Covered for adults > 19 years of age for all LOBs (Influenza virus vaccine) Covered for adults > 19 years of age for all LOBs (Hepatitis A and Hepatitis B combo vaccine) Covered for adults 19 years of age for all LOBs (Hepatitis A vaccine) Covered for adults 19 years of age for all LOBs (Injectable influenza vaccine) Covered for adults 19 years of age for all LOBs (Nasal influenza vaccine) Covered for adults 19 years of age through 49 for all LOBs (Meningococcal Conjugate vaccine) Covered for adults 19 years of age for all LOBs

2 90707 (Measles, Mumps, and Rubella vaccine) Covered for adults 19 years of age for all LOBs (Tetanus Toxoid and Diphtheria vaccine) Covered for adults 19 years of age for all LOBs (Varicella virus vaccine) Covered for adults 19 years of age for all LOBs (Pneumococcal polysaccharide vaccine) Covered for adults 19 years of age for all LOBs Not covered (Adenovirus vaccine, type 4) - Not covered for all LOBs (Adenovirus vaccine, type 7) - Not covered for all LOBs (Anthrax vaccine) - Not covered for all LOBs (Bacillus Calmmette-Guerin vaccine for TB live) - Not covered for all LOBs (Bacillus Calmmette-Guerin vaccine for bladder cancer, live) - Not covered for all LOBs (Hib, HbOC) - Not covered (similar CPT code is covered under VFC) (Hib, PRP-D) - Not covered (similar CPT code is covered under VFC) (Influenza virus) Not covered (similar CPT code is covered under VFC) (Lyme disease vaccine) Not covered (vaccine is withdrawn from the market) (Meningococcal polysaccharide vaccine) Not covered (similar CPT code is covered under VFC) (Mumps virus vaccine) Not covered (similar CPT code is covered under VFC) (Measles virus vaccine) Not covered (similar CPT code is covered under VFC) (Rubella virus vaccine) Not covered (similar CPT code is covered under VFC) (Measles and Rubella virus vaccine) Not covered (similar CPT code is covered under VFC) (Tetanus and diphtheria toxoids) Not covered (similar CPT code is covered under VFC) (Unlisted vaccine) Not covered, as not specific to a particular vaccine; all recommended vaccines have unique CPT codes (Diphtheria toxoid) Not covered (similar CPT code is covered under VFC) We welcome your feedback on the above-noted changes and ask that any comments, concerns or suggestions be communicated to Anish Patel, PharmD, Clinical Pharmacist, at (718) (ext 11301), via fax at (718) or via at apatel@fideliscare.org

3 Fidelis Care New York Coverage of Immunizations for Children (0 to <19 yo) and Adults (19-64 yo) for all Lines of Business (Child Health Plus [CHP], Family Health Plus [FHP], and Medicaid Managed Care [NYM]) 2/1/2012 CHP and NYM (0 to <19 yo) FHP and NYM (19-64 yo) The Administration fee and Cost will be reimbursed to MDs for vaccine CPT codes in the attached Appendix B; utilization management controls may apply (as listed) The Administration fee ONLY will be covered for vaccine CPT codes in the attached Appendix A (reimbursement for the cost of the vaccines themselves should be obtained via Vaccines for Children [VFC] program)* The Administration fee and Cost will be reimbursed to MDs for vaccine CPT codes listed below (utilization management controls may apply as noted below). These vaccines are NOT covered via VFC: (Rabies vaccine) covered without restrictions (Rabies vaccine) covered without restrictions (Typhoid vaccine) covered with prior authorization (Typhoid vaccine) covered with prior authorization (Typhoid vaccine) covered with prior authorization (Typhoid vaccine) covered with prior authorization (Cholera vaccine) covered with prior authorization (Plague vaccine) covered with prior authorization (Japanese encephalitis virus vaccine) covered with prior authorization (Yellow fever vaccine) covered with prior authorization (Tetanus Toxoid) Covered for ages 7 yo to 18 yo (Influenza virus vaccine) Covered for ages 3 yo to 18 yo *To become a registered provider with VFC, please go to this website: The contact information for NYC VFC coordinator is listed below: New York City Angel Lapaz Dept of Health, Bureau of Immunization 455 First Ave New York, N.Y Phone: Fax: alapaz@health.nyc.gov

4 Appendix A COVERED VACCINE CPT CODES FOR CHILDREN UNDER CHP AND NYM (0 to <19 YO) THROUGH VACCINES FOR CHILDREN PROGRAM (2/1/12) VACCINE FULL NAME OF VACCINE DT Diphtheria Tetanus Toxoid vaccine DTAP (Tripedia) Diphtheria, Tetanus Toxoid, Acellular Pertussis vaccine DTAP (Daptacel) Diphtheria, Tetanus Toxoid, Acellular Pertussis vaccine DTAP (Infanrix) Diphtheria, Tetanus Toxoid, Acellular Pertussis vaccine DtaP-Hep B-IPV (Pediarix) Diphtheria, Tetanus Toxoid, Acellular Pertussis, Hepatitis B DTAP/HIB (Trihibit) Diphtheria, Tetanus Toxoid, Acellular Pertussis and Haemophilus Influenza B vaccine e-ipv (Ipol) Inactivated poliovirus vaccine HEPATITIS A PED (Vaqta) Hepatitis A Pediatric vaccine HEPATITIS A PED (Havrix) Hepatitis A Pediatric vaccine HEPATITIS B (PED/ADOL) Hepatitis B pediatric/adolescent vaccine HEPATITIS B (PED/ADOL) Hepatitis B pediatric/adolescent vaccine HEPATITIS B -2 dose (11-15 only) Hepatitis B adult - 2 dose vaccine HEPATITS A-HEPATITIS B (18 year olds for VFC) Hepatitis A and Hepatitis B combo vaccine (Twinrix) HEP B HIB (Comvax) Hepatitis B and Haemophilus Influenza B vaccine HIB (Pedvax) Haemophilus B conjugate vaccine HIB (Acthib) Haemophilus B conjugate vaccine HIB (Hiberix) Haemophilus B conjugate vaccine HPV (Gardasil) Human Papillomavirus Quadrivalent (Types 6, 11, 16, and 18) HPV (Cervarix) Human Papillomavirus Bivalent (Types 16 and 18) INFLUENZA (Fluzone) INFLUENZA PF (6M-35MONTHS) (Fluzone PF) INFLUENZA PF (Fluvirin PF), (Agriflu) INFLUENZA (NASAL) (Flumist) MENINGOCOCCAL CONJUGATE Meningococcal Conjugate vaccine MMR (MMR II) Measles, Mumps and Rubella vaccine MMR-V (Proquad) Measles, Mumps and Rubella and Varicella Vaccine ROTAVIRUS (Rotateq) Rotavirus vaccine ROTAVIRUS (Rotarix) Rotavirus vaccine TD (Decavac) Tetanus Toxoid and Diphtheria vaccine TD Tetanus Toxoid and Diphtheria vaccine VARICELLA (Varivax) Varicella virus vaccine PNEUMOCOCCAL (Prevnar) Pneumococcal conjugate vaccine PNEUMOCOCCAL (2 yr and up) Pneumococcal polysaccharide vaccine TDAP (Boostrix) Tetanus Toxoid and Diphtheria and acellular pertussis vaccine TDAP (Adacel) Tetanus Toxoid and Diphtheria and acellular pertussis vaccine DTAP-IPV (Kinrix) Diphtheria, Tetanus Toxoid, Acellular Pertussis vaccine and Inactivated poliovirus vaccine DTAP-IPV-HIB (Pentacel) Diphtheria, Tetanus Toxoid, Acellular Pertussis vaccine and Inactivated poliovirus vaccine and Haemophilus Influenza B vaccine CPT CODE

5 Appendix B COVERED VACCINE CPT CODES FOR ADULTS UNDER FHP AND NYM YO (2/1/12) VACCINE FULL NAME OF VACCINE CPT CODE Comments/UM controls DT Diphtheria Tetanus Toxoid vaccine Covered for adults > 19 yo Tetanus Toxoid Tetanus Toxoid Covered for adults > 19 yo Diphtheria Antitoxin Diphtheria Antitoxin Covered, no age restrictions TIG (Baytet) Tetanus immune globulin Covered, no age restrictions HBIG (BayHepB, Nabi-HB) Hepatitis B immune globulin Covered, no age restrictions HEPATITIS A Adult (Vaqta, Havrix) Hepatitis A Adult vaccine Covered for adults > 19 yo HEPATITIS B (Engerix-B, Recombivax-HB) Hepatitis B adult vaccine (40mcg dose) Covered for adults > 19 yo HEPATITIS B (Engerix-B, Recombivax-HB) Hepatitis B adult vaccine Covered for adults >20 yo HEPATITIS B (Engerix-B, Recombivax-HB) Hepatitis B adult dialysis (40mcg dose) Covered, no age restrictions HEPATITS A-HEPATITIS B (Twinrix) Hepatitis A and Hepatitis B combo vaccine Covered for adults > 19 yo INFLUENZA (Fluzone, Fluvirin) Injectable influenza vaccine Covered for adults > 19 yo INFLUENZA (Flumist) Nasal influenza vaccine Covered for adults > 19 yo through <49 INFLUENZA (Fluzone PF, Fluarix) Injectable influenza vaccine - preservative free Covered for adults > 19 yo MENINGOCOCCAL CONJUGATE (Menactra) Meningococcal Conjugate vaccine Covered for adults > 19 yo MENINGOCOCCAL CONJUGATE (Menveo) Meningococcal Conjugate vaccine MMR (MMR II) Measles, Mumps and Rubella vaccine Covered for adults > 19 yo TD Tetanus Toxoid and Diphtheria vaccine Covered for adults > 19 yo VARICELLA (Varivax) Varicella virus vaccine Covered for adults > 19 yo VZIG Varicella zoster immune globulin Covered, no age restrictions PNEUMOCOCCAL (Pneumovax) Pneumococcal polysaccharide vaccine Covered for adults > 19 yo PNEUMOCOCCAL (Prevnar) Pneumococcal conjugate vaccine Covered for adults > 19 yo TDAP (Adacel) Tetanus Toxoid and Diphtheria and acellular pertussis vaccine Covered for adults > 19 yo HPV (Gardasil) Human Papillomavirus Quadrivalent Covered only for ages > 19 yo through < 26 HPV (Cervarix) Human Papillomavirus Bivalent Covered only for females > 19 yo through < 25 Rabies vaccine (RabAvert) Rabies vaccine (intramuscular injection) Covered, no age restrictions Rabies vaccine (Immovax Rabies I.D.) Rabies vaccine (intradermal injection) Covered, no age restrictions RIG Rabies immune globulin Covered, no age restrictions Typhoid vaccine, live oral Ty21 (Vivitif Berna) Typhoid vaccine, live, oral Covered, no age restrictions Typhoid (Typhim Vi) Typhoid vaccine, for intramuscular use Covered, no age restrictions Typhoid vaccine Typhoid vaccine, for subcutaneous or intradermal use Covered, no age restrictions Typhoid vaccine Typhoid vaccine, for subcutaneous use (U.S. Military) Covered, no age restrictions Cholera vaccine Cholera vaccine for injectable use Covered, no age restrictions Plague vaccine Plague vaccine for intramuscular use Covered, no age restrictions Japanese encephalitis virus vaccine Japanese encephalitis virus vaccine for subcutaneous use Covered, no age restrictions Yellow fever vaccine Yellow fever vaccine, live, for subcutaneous use Covered, no age restrictions DTAP-IPV (Kinrix) Diphtheria, Tetanus Toxoid, Acellular Pertussis vaccine and Inactivated poliovirus vaccine Covered for adults > 19 yo DTAP-IPV-HIB (Pentacel) Diphtheria, Tetanus Toxoid, Acellular Pertussis vaccine and Inactivated poliovirus vaccine and Haemophilus Influenza B Covered for adults > 19 yo

6 vaccine Zoster Vaccine (Zostavax) Zoster (shingles) vaccine, live, for subcutaneous injection Covered for adults > 60 yo