|
*REIMBURSEMENT RATES ARE FOR PRIMARY CARE PHYSICIANS WHO HAVE SIGNED THE CURRENT AMENDMENT.
THIS DOCUMENT IS BASED ON FINANCIAL RISK ONLY, IT IS NOT A GUARANTEE OF MEMBER BENEFITS.
|
DT
|
90702
|
$36.05
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
DTAP
|
90700
|
$27.77
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
DTAP-HEP B-IPV
|
90723
|
$70.30
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
DTAP-HIB
|
90721
|
$40.63
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
GARDASIL (18 and over)
|
90649
|
$134.73
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
GARDASIL (under 18)
|
90649
|
$134.73
|
AETNA
|
BLUE CROSS
|
IPA
|
CIGNA
|
HEALTHNET
|
GREAT WEST
|
PACIFICARE
|
SCAN
|
|
|
HEP B (2 DOSE ADOLESCENT)
|
90743
|
$21.11
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
EFF 9/1/2007
|
|
HEP B (ADULT)
|
90746
|
$50.69
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
EFF 9/1/2007
|
|
HEP B (CHILD & ADOLESCENT)
|
90744
|
$21.11
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
EFF 9/1/2007
|
|
HEP B-HIB
|
90748
|
$39.22
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
EFF 9/1/2007
|
|
HEPATITIS A (ADULT)
|
90632
|
$55.90
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
HEPATITIS A (PED)
|
90633
|
$41.25
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
DUE TO SHORTAGE, THIS RATE APPLIES UNTIL 10/31/2008
|
|
HIB, HBOC CONJUGATE (4 DOSE SCHED)
|
90645
|
$28.44
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
HIB, PRP-D CONJUGATE (BOOSTER USE ONLY)
|
90646
|
$28.44
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
HIB, PRP-OMP CONJUGATE (3 DOSE SCHED)
|
90647
|
$28.44
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
HIB, PRP-T CONJUGATE (4 DOSE SCHED)
|
90648
|
$28.44
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
INFLUENZA (18 and over)
|
90656
|
$28.13
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
INFLUENZA (18 and over)
|
90658
|
$28.13
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
INFLUENZA (under 18)
|
90656
|
$28.13
|
AETNA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
INFLUENZA (under 18)
|
90658
|
$28.13
|
AETNA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
KINRIX
|
90696
|
$60.50
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
MENACTRA (18 and over)
|
90734
|
$104.51
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
MENACTRA (under 18)
|
90734
|
$104.51
|
AETNA
|
BLUE CROSS
|
IPA
|
CIGNA
|
HEALTHNET
|
GREAT WEST
|
PACIFICARE
|
SACN
|
|
|
MENINGOCOCCAL
|
90733
|
$108.18
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
MENINGOCOCCAL (Age 11-17)
|
90733
|
$108.18
|
AETNA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
MMR
|
90707
|
$55.55
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
MMRV (PROQUAD)
|
90710
|
$130.87
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
PEDIATRIC INFLUENZA
|
90655
|
$28.13
|
AETNA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
PEDIATRIC INFLUENZA
|
90657
|
$28.13
|
AETNA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
PENTACEL
|
90698
|
$63.28
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
PNEUMOCOCCAL
|
90732
|
$40.61
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
POLIOVIRUS
|
90713
|
$30.65
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
PREVNAR
|
90669
|
$95.63
|
AETNA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
GREAT WEST
|
IPA
|
IPA
|
Rate effective 10/01/08
|
|
Rho(D)
|
90385
|
$53.66
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
ROTAVIRUS
|
90680
|
$79.36
|
AETNA
|
BLUE CROSS
|
IPA
|
CIGNA
|
HEALTHNET
|
GREAT WEST
|
PACIFICARE
|
SCAN
|
|
|
TD
|
90714
|
$31.64
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
TD
|
90718
|
$31.64
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
TDAP (BOOSTRIX/ADACEL (18 and over)
|
90715
|
$47.11
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
TDAP (BOOSTRIX/ADACEL (under 18)
|
90715
|
$47.11
|
AETNA
|
BLUE CROSS
|
IPA
|
CIGNA
|
HEALTHNET
|
GREAT WEST
|
PACIFICARE
|
SCAN
|
|
|
TETANUS
|
90703
|
$31.64
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
TYPHOID
|
90691
|
$58.05
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
VARICELLA
|
90716
|
$83.96
|
IPA
|
BLUE CROSS
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
IPA
|
|
|
ZOSTAVAX (ADULT IMMUNIZATION OVER AGE 60)
|
90736
|
$163.35
|
AETNA SENIOR
|
BLUE CROSS
|
IPA
|
CIGNA
|
HEALTHNET SENIOR
|
GREAT WEST
|
SECURE HORIZONS
|
SCAN
|
SENIOR PLANS UNDER PART D BENEFIT
|
Reimbursement rates include the $12.50 administration fee.
New rates are effective as of 09/01/2008.
|
